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.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Pulmonary Hypertension, Interventions and Structural Heart Disease, Mitral Regurgitation

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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