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Periprocedural Pulmonary Hypertension and TAVR Outcomes
Quick Takes
- Periprocedural pulmonary hypertension (PH) status significantly risk-stratified outcomes after TAVR.
- Patients with normalized PH had similar outcomes as those with no PH, while new-onset PH and presence of residual PH were related to increased risk for mortality and rehospitalization for heart failure.
- These data further underscore the need for early recognition and treatment of aortic stenosis and more aggressive secondary prevention after TAVR to optimize outcomes.
Study Questions:
What is the prognostic impact of normalized, new-onset, and residual pulmonary hypertension (PH) after transcatheter aortic valve replacement (TAVR)?
Methods:
The investigators analyzed data from the OCEAN-TAVI (Optimized Transcatheter Valvular Intervention–Transcatheter Aortic Valve Implantation) registry, an ongoing, multicenter Japanese registry that includes 2,588 patients who underwent TAVR. Patients were classified into four groups according to periprocedural systolic pulmonary artery pressure by echocardiography: no PH before and after TAVR (no PH), PH before but not after TAVR (normalized PH), PH after but not before TAVR (new-onset PH), and PH before and after TAVR (residual PH). A systolic pulmonary artery pressure cutoff of >36 mm Hg was applied for PH. The primary endpoint was all-cause mortality at 2 years. Logistic regression analysis was used to identify clinical predictors of residual and new-onset PH.
Results:
In total, 1,872 patients were divided into four groups: 1,027 (54.9%) in the no PH group, 257 (13.7%) in the normalized PH group, 280 (15.0%) in the new-onset PH group, and 308 (16.5%) in the residual PH group. There was a significant difference in all-cause mortality among the four groups at 2 years (11.0%, 12.8%, 18.6%, and 24.7%, respectively; p < 0.01). Among 565 patients who had preprocedural PH, 257 (45.5%) experienced normalization of PH, with mortality comparable with that in the no PH group. In multivariable logistic regression analysis, predictors of residual PH after TAVR were atrial fibrillation (AF) and baseline tricuspid regurgitation (TR) moderate or greater, whereas prosthesis-patient mismatch was a predictor of new-onset PH.
Conclusions:
The authors concluded that risk stratification on the basis of post-TAVR PH status can identify patients at increased mortality after TAVR.
Perspective:
This registry study reports that periprocedural PH status significantly risk-stratified outcomes after TAVR. Patients with normalized PH had similar outcomes as those with no PH, while new-onset PH and residual PH were related to increased risk for mortality and rehospitalization for heart failure. Predictors of residual PH after TAVR were AF, baseline TR moderate or greater, severe PH, and preserved left ventricular ejection fraction, whereas baseline moderate or greater TR, post-TAVR mitral regurgitation moderate or greater, and permanent pacemaker were identified as predictors of new-onset PH. Overall these data suggest that while TAVR can reduce pulmonary arterial pressure, PH developing or persisting after TAVR is associated with an elevated risk of mortality and hospitalization for heart failure. These data further underscore the need for early recognition and treatment of aortic stenosis and more aggressive secondary prevention after TAVR to optimize outcomes.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension, Mitral Regurgitation
Keywords: Aortic Valve Stenosis, Arterial Pressure, Atrial Fibrillation, Cardiac Surgical Procedures, Echocardiography, Heart Failure, Heart Valve Diseases, Hypertension, Pulmonary, Mitral Valve Insufficiency, Pacemaker, Artificial, Prostheses and Implants, Risk Assessment, Secondary Prevention, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency
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