Impact of the new pulmonary hypertension definition on long‐term mortality in patients with severe aortic stenosis undergoing valve replacement

Abstract

Background The new 2018 pulmonary hypertension (PH) definition includes a lower mean pulmonary artery pressure (mPAP) cut‐off (>20 mmHg rather than ≥25 mmHg) and the compulsory requirement of a pulmonary vascular resistance (PVR) ≥3 Wood units (WU) to define precapillary PH. We assessed the clinical impact of the 2018 compared to the 2015 PH definition in aortic stenosis (AS) patients undergoing aortic valve replacement (AVR). Methods Severe AS patients (n = 487) undergoing pre‐AVR right heart catheterization were classified according to the 2015 and 2018 definitions. Post‐AVR mortality (median follow‐up 44 months) was assessed. Results Based on the 2015 definition, 66 (13%) patients exhibited combined pre and postcapillary PH (CpcPH), 116 (24%) isolated post‐capillary PH (IpcPH), 28 (6%) precapillary PH, and 277 (57%) no PH at all. Overall, 52 (11%) patients were reclassified: 23 no PH into IpcPH; 8 no PH into precapillary PH; 20 precapillary PH into no PH; 1 CpcPH into IpcPH. By the 2015 definition, only CpcPH patients displayed increased mortality, whereas by the 2018 definition, precapillary PH patients also experienced higher mortality than those without PH. Among the PH definition components, PVR ≥3 WU was the strongest predictor of death (hazard ratio > 4). Conclusions In severe AS, a higher number of IpcPH patients are diagnosed by the 2018 definition, even though they have the same prognosis as those without PH. Patients with true precapillary PH are more accurately identified by the 2018 definition that includes a pulmonary vascular disease criterion, that is, PVR ≥3 WU, a strong mortality predictor.

Hemodynamics Prior to Valve Replacement for Severe Aortic Stenosis and Pulmonary Hypertension during Long-Term Follow-Up

“…A waiver of consent was granted. We have previously reported on other aspects of the hemodynamics in this population [11][12][13][14][15][16][17].…”

“…Given the recent controversy about use of the DPG for the definition of CpcPH [23] and the conflicting data on its prognostic value [24], and the fact that the application of the original 2015 ESC/ERS definition results in unclassifiable patients (i.e., those with discordant PVR and DPG: PVR ≤ 3 WU but DPG ≥ 7 mmHg or PVR > 3 WU but DPG < 7 mmHg) [ [22,23], and it is not clearly stated either whether any patient with mPAP > 20 mmHg should be classified as having PH. Therefore, we assumed that these patients do not have PH as there was not clear evidence for pulmonary vascular disease and/or elevated left atrial pressure [15].…”

Prognostic Implications of the Novel Pulmonary Hypertension Definition in Patients with Aortic Stenosis after Transcatheter Valve Replacement

“…Moreover, in a recent study by Maeder et al, despite a slight reclassification effect, PH remained a significant determinant of all-cause mortality. At the same time, the high PVR criterion displayed the strongest association with poor outcomes [ 16 ].…”

Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Systematic Review of Non-Invasive Ways of Risk Stratification, Especially in Patients Undergoing Transcatheter Aortic Valve Replacement

“…It should mean that adverse cardiac remodeling associated with moderate to severe AS plays a central role in the development of other cardiovascular and cerebrovascular events, such as atrial fibrillation, TIA/stroke, acute coronary syndrome/acute myocardial infarction, conversion of HF with preserved ejection fraction to HF with reduced ejection fraction and fatal arrhythmias/sudden cardiac death [66,67]. PH is not only frequently accompanied by adverse cardiac remodeling, but it is also promoted by cumulative effects of HF, atrial fibrillation and other factors such as preload and afterload, skeletal muscle weakness and metabolic disease (diabetes, obesity and thyroid dysfunction) [68][69][70][71][72]. In this context, cardiac biomarkers reflecting biomechanical stress (natriuretic peptides (NPs), myocardial damage (high-sensitivity cardiac troponins), inflammation (soluble suppression of tumorigenicity 2 (sST2), fibrosis (galectin-3, GDF-15), oxidative stress and endothelial dysfunction are considered useful for clinicians to improve risk stratification models to better manage their patients.…”