Negative Impact of Pulmonary Hypertension in TAVR

Courtesy of Dr. Carlos Fava.

The presence of pulmonary hypertension (PH) is frequent in severe aortic stenosis. This can be classified in: isolated pre-capillary PH, isolated post-capillary PH, and combined post-capillary and pre-capillary PH. 

At present, little research has looked into the disease from this perspective. 

The study looked at 1400 patients and divided them into 4 groups: 658 had no PH (mPAP< 25 mmHg), 139 had isolated pre-capillary PH (mPAP ≥25 mmHg and capillary wedge pressure ≤15 mmHg), 534 had isolated post-capillary PH (mPAP≥ 25 mmHg and capillary wedge pressure >15 mmHg), and 69 combined post-capillary and pre-capillary PH (mPAP≥ 25 mmHg, capillary wedge pressure >15 mmHg and pulmonary diastolic gradient ≥7 mmHg).

Mean age was 81 and 46% were men. The 3 groups with PH had more prevalence of AS and more comorbidities. 

Read also: Pulmonary Hypertension: No Reason for TAVR Contraindication.

Procedural success was 94.9%, with no differences in leaks, stroke, bleeding, vascular complication and kidney failure. In hospital mortality was higher in patients presenting isolated pre-capillary and isolated post-capillary PH.

12 month and 4 year follow ups showed lower mortality in patients with no PH vs those with PH [at one year 13.8% vs 23.4% (p<0.001) and at 4 years 37.2 vs. 51.5% (p<0.001)].

At one year, mortality was nearly twice as high patients with isolated pre-capillary HP, and patients with isolated post-capillary PH experienced a 1.5 mortality increase vs. those with no PH. There were no differences in survival in patients with PH.  

In 25% of patients with isolated pre-capillary PH and isolated post-capillary PH the process was reversible, which was associated with better survival. This did not happen in patients with combined post-capillary and pre-capillary PH. 

Read also: TCT 2018 | PADN-5: Pulmonary Artery Denervation in Pre- and Post-Capillary Pulmonary Hypertension.

Functional class improved at follow up in all groups. Mortality predictors at one year were age, glomerular filtration, COPD, stroke, cardiac index, PH, isolated pre-capillary PH, and isolated post-capillary PH. 

Conclusion

Patients with isolated pre-capillary and isolated post-capillary PH showed higher mortality after TAVR compared to patients with no PH. Reversible PH did no show benefits except in patients with isolated pre-capillary PH.

Hemodynamic stratification of PH helps predict risk and AS patient response after TAVR. 

Courtesy of Dr. Carlos Fava.

Original Title: Impact of Pulmonary Hypertension Hemodynamic Status on Long-Term Outcome After Transcatheter Aortic Valve Replacement.

Reference: Jury Schewel, et al. J Am Coll Cardiol Intv 2019;12:2155–68.

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