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Prognostic Impact of PH After TAVR
Study Questions:
What are predictors of pulmonary hypertension (PH) regression and its impact on short-, mid-, and long-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS)?
Methods:
A total of 617 patients who underwent TAVR for severe AS between 2009 and 2014 was stratified by tertials of pulmonary artery systolic pressure (PASP) pre- and post-procedure. Primary outcome was all-cause mortality at 30 days, 1 year, and long-term follow-up at maximum of 5.9 years.
Results:
A total of 647 patients (n = 303 men, 49%) with severe AS undergoing TAVR was included in the study. Of that total, 136 of the patients (22%) had normal PASP, 260 (42%) had mild to moderate PH, and 221 (36%) had severe PH. Patients with severe PH had smaller aortic valve area (0.66 ± 0.19); higher prevalence of moderate-to-severe mitral regurgitation (MR), tricuspid regurgitation (TR), and aortic regurgitation (AR); and higher left atrial volume and end diastolic filing index than patients who had normal PASP. In patients with mild-to-moderate and severe PH at baseline, PASP decreased significantly at discharge (∆PASP 3.0 ± 9.3 mmHg and 12.0 ± 10.0 mmHg, respectively) and 1 year (∆PASP 5.0 ± 9.7 mmHg and 18 + 14 mmHg, respectively) after TAVR. Patients with residual PH had a higher risk of all-cause mortality at 30 days (hazard ratio [HR] 3.49; 95% confidence interval [CI], 1.74-6.99; p < 0.001), 1 year (HR 3.12; 95% CI, 2.06-4.72; p < 0.001), and long term (HR 2.47; 95% CI, 1.74-3.49; p < 0.001). Patients with moderate-to-severe MR and TR had a significant reduction at discharge and 1 year after TAVR. The researchers identified left ventricular ejection fraction (LVEF) >40% (odds ratio [OR] 3.56; 95% CI, 2.24-5.65; p < 0.001), baseline PASP >46 mmHg (OR 3.26; 95% CI, 2.07-5.12; p < 0.001), absence of concomitant tricuspid regurgitation > moderate (OR 0.53; 95% CI, 0.34-0.84; p < 0.001), and logistic EuroSCORE <25% (OR 1.59; 95% CI, 1.04-2.45; p = 0.03) as independent predictors of PASP reduction. A total of 46% (n = 237) of patients with PH had a significant change from mild-moderate to none or severe to mild-moderate. Right ventricular function improved in all groups of PH after TAVR. All-cause mortality was similar among baseline PASP groups at all time intervals.
Conclusions:
Patients with PH who have severe AS and undergo TAVR can see a significant improvement in PH. Patients with reversible PH after TAVR are at lower risk of all-cause mortality.
Perspective:
Patients with severe AS who are undergoing TAVR may see a significant reduction in PH, with reduction of MR and TR and improvement of right ventricular dysfunction. The authors recommended that PH should not be a contraindication for TAVR. Work-up of underlying cause of PH prior to TAVR may help identify those who would benefit from treatment.
Keywords: Hypertension, Pulmonary, Transcatheter Aortic Valve Replacement, Aortic Valve Insufficiency, Aortic Valve, Mitral Valve Insufficiency, Tricuspid Valve Insufficiency, Ventricular Function, Right, Ventricular Dysfunction, Right, Pulmonary Artery, Aortic Valve Stenosis, Heart Valve Prosthesis
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