Original title: Post-Procedural Hypertension Following Transcatheter Aortic Valve Implantation Incidence and Clinical Significance. Reference: Gidon Y. Perlman et al. J Am Coll Cardiol Intv 2013. Article in press.

Pre-procedural hypertension (HTN) is a risk factor and a predictor of increased mortality after surgical aortic valve replacement (AVR). The disappearance of the pressure gradient across the aortic valve following surgical AVR often leads to dramatic hemodynamic changes and increased hypotension. This study prospectively looks into hemodynamic changes after transcatheter aortic valve implantation (TAVI) and its clinical implications at 12 months follow up. Patients were divided into 2 groups, according to the presence or the increase of blood pressure after TAVI. Increased BP after TAVI was defined as sustained systolic pressure >140 mm Hg or diastolic pressure >90 mm Hg that was not present at baseline, before TAVI; the need to double the dosage of an antihypertensive drug; the need to add an additional drug to the pre-procedural scheme.

Outcomes were assessed at 30 days and 12 months; all cause death, infarction, stroke, heart failure and recurrent hospitalization were considered adverse events. 105 consecutive patients were included. Overall, systolic BP increased immediately after TAVI in the entire cohort by an average of 15 ± 31 mm Hg., which still remained 8 mmHg above baseline at 5 days after procedure, despite treatment (p<0.01 for both), diastolic pressure, on the other hand, saw a significant reduction. 53 patients out of 105 (51%) fulfilled on of the criteria for increased BP above mentioned, which required intensified treatment or even antihypertensive drugs, temporarily.

Baseline characteristics were similar in both groups, with the exception of BMI (Body mass index) and number of drugs to reach similar BP at baseline, before TAVI. Cardiac output, cardiac index, and stroke volume after TAVI were significantly increased in patients with increased BP versus patients with stable BP (p < 0.05). The rates of in-hospital, 30 day, and 12-month serious adverse events were 21%, 30%, and 53%, respectively, for patients with increased BP as compared to 60%, 71%, and 83% for patients with stable BP (p < 0.01 for all differences between groups). Most of these events were episodes of worsening heart failure and there were no differences in mortality rate. The rates of procedure-related complications with possible hemodynamic consequences including bleeding, vascular complications, pacemaker implantation, and aortic insufficiency did not differ significantly between the groups.

Conclusion: 

Around 50% of post TAVI patients present a significant increase of systolic BP, requiring immediate and prolonged treatment. So far, this has been the first study to show that this phenomenon predicts a better evolution of heart function and an even better short and midterm evolution.

Editorial Comment: 

The rise in BP may represent myocardial contractile reserve, already similarly described in dobutamine stress echocardiography and aortic stenosis studies. The rise in BP may represent a lack of adverse events such as vascular injury and bleeding. However, there were no significant differences in the rates of procedural complications between the two groups.

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