Pulmonary Hypertension: No Reason for TAVR Contraindication

In most severe aortic stenosis patients with pulmonary hypertension, transcatheter aortic valve replacement (TAVR) reduced pulmonary systolic pressure.

There patients presented lower risk and lower all-cause mortality at short, median and long term. This data show that pulmonary hypertension should not be a TAVR contraindication.

Pulmonary hypertension is common among TAVR patients. The most frequent treatment is associated to hypotension regression, even though regression predictors and prognosis remain unknown.

This study included 617 consecutive patients undergoing TAVR between 2009 and 2015, stratified in terciles according to baseline pulmonary artery systolic pressure, resulting in: normal (PASP <34 mm Hg), mild to moderate (34 mm Hg ≤ PASP 46 mm Hg) and severe pulmonary hypertension (PASP ≥46 mm Hg). After TAVR, 520 patients with pulmonary hypertension at discharge were re-stratified according to presence or absence of pulmonary hypertension reduction.

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Primary endpoint was all cause mortality at 30 days, one year and 5.9 long term follow up.

Patients with mild to moderate baseline pulmonary hypertension showed significant reduction at discharge and at one year. All-cause mortality risk resulted similar in all patients with baseline pulmonary hypertension in all time intervals.

After TAVR, nearly half of patients (46%) showed a significant reduction of pulmonary hypertension.

The opposite occurred with patients with residual pulmonary hypertension where mortality at 30 days (HR: 3.49; p<0.001) and one year (HR: 2.47; p<0.001) was quite higher.

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Left ventricular ejection fraction >40%, severe baseline pulmonary hypertension, the absence of mild to moderate concomitant tricuspid failure and EuroSCORE log <25 were independent predictors of pulmonary hypertension reduction.

Conclusion

Many patients undergoing TAVR present concomitant pulmonary hypertension and this procedure was associated with significant pulmonary hypertension reduction at short and long term. Patients who saw pulmonary hypertension reduction also saw mortality reduction at short mid and long term. The presence of pulmonary hypertension should not contraindicate transcatheter aortic valve replacement.

Original Title: Pulmonary Hypertension in Patients With Severe Aortic Stenosis: Prognostic Impact After Transcatheter Aortic Valve Replacement. Pulmonary Hypertension in Patients Undergoing TAVR.

Reference: Brunilda Alushi et al. JACC Cardiovasc Imaging. 2019 Apr;12(4):591-601.

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