Impact of pulmonary hypertension on outcomes after aortic valve replacement for aortic valve stenosis

Abstract

Objective The presence of pulmonary hypertension (PH) historically has been considered a significant risk factor affecting early and late outcomes following valve replacement. Given the number of recent advances in the management of PH following cardiac surgery a better understanding of the impact of PH on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine if pulmonary hypertension remains a risk factor in the modern era for adverse outcomes following aortic valve replacement (AVR) for aortic valve stenosis. Methods From January 1996 to June 2009, 1,080 patients underwent AVR for primary aortic valve stenosis, of which 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had PH. PH was defined as mild (sPAP 35-44 mmHg), moderate (45-59mmHg), or severe (≥ 60mmHg). In the group of patients with PH, 204 had postoperative echocardiograms. Results Operative mortality was significantly higher in patients with PH (47/506, 9% versus 31/574, 5%; p=0.02). The incidence of postoperative stroke was similar (p=0.14), but patients with PH had an increased median hospital LOS (8 versus 7 days, p=0.001) and an increased incidence of prolonged ventilation (26% versus 17%, p<0.001). Preoperative PH was an independent risk factor for decreased long term survival (RR 1.7, p=0.02). Those with persistent PH postoperatively had decreased survival. Five-year survival (Kaplan-Meier) was 78 ± 6% with normal sPAP and 77 ± 7% with mild PH postoperatively, compared to 64 ± 8% with moderate PH and 45 ± 12% with severe PH (p<0.001). Conclusion In patients undergoing AVR, preoperative PH increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe PH after AVR had decreased long-term survival. These data suggest that PH had a significant impact on outcomes in patients undergoing AVR and should be considered in preoperative risk assessment.

Prognostic Implications of Pulmonary Hypertension in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

“…Likewise, Tamburino et al, 11 in 663 consecutive patients who underwent TAVI with the CoreValve device, did not identify severe PH as an independent predictor of 30-day mortality. In contrast, PH has early clinical implications after surgical AVR: Melby et al, 24 in 1080 patients who underwent AVR for primary aortic valve stenosis, found significantly higher 30-day mortality in patients with PH (9.3% versus 5.4%; P=0.18). Severe PH was also an independent predictor of early mortality in the study of Di Eusanio et al 25 of 2256 patients managed by AVR (odds ratio, 5; 95% CI, 1.1-5.9).…”

Pulmonary Vascular Hemodynamic Response to Exercise in Cardiopulmonary Diseases

“…55 The presence of PH at rest or during exercise should therefore be included in perioperative risk assessment of mitral and aortic valve replacement. 56,57 In older patients with severe mitral valve stenosis and PH, the perioperative mortality increases to 20%; therefore, the indication of valve surgery has to be proven carefully. 56 Preoperative PH was also an independent risk factor for long-term survival in patients with aortic valve replacement.…”

“…56 Preoperative PH was also an independent risk factor for long-term survival in patients with aortic valve replacement. 57,58 Patients with valvular disease and normal or mildly elevated PASP at rest may develop severe PH during exercise, which may be unrelated to the resting pressure. 37,59 The level of increase in PASP depends on the ability to successfully recruit the pulmonary vasculature to accommodate increased blood flow with exercise, the contribution (or proportion) of the reduction in cross-sectional area of the pulmonary circulation, the reduction in pulmonary vascular compliance, and the increase in LAP, each of which may be abnormal at rest.…”

Pulmonary hypertension in left heart disease

“…PH is a common complication of mitral valve disease and may affect as many as 73% of patients depending on disease severity [32,33]. The prevalence of PH in patients with aortic stenosis is lower than in those with mitral stenosis but is still considerable at ,30-50% [34][35][36].…”