Risk stratification in patients with pulmonary hypertension undergoing transcatheter aortic valve replacement.
OBJECTIVE
Pulmonary hypertension (PH) is associated with increased mortality after surgical or transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS), and when the pulmonary artery pressure is particularly elevated, there may be questions about the clinical benefit of TAVR. We aimed to identify clinical and haemodynamic factors associated with increased mortality after TAVR among those with moderate/severe PH.


METHODS
Among patients with symptomatic AS at high or prohibitive surgical risk receiving TAVR in the Placement of Aortic Transcatheter Valves (PARTNER) I randomised trial or registry, 2180 patients with an invasive measurement of mean pulmonary artery pressure (mPAP) recorded were included, and moderate/severe PH was defined as an mPAP ≥35 mm Hg.


RESULTS
Increasing severity of PH was associated with progressively worse 1-year all-cause mortality: none (n=785, 18.6%), mild (n=838, 22.7%) and moderate/severe (n=557, 25.0%) (p=0.01). The increased hazard of mortality associated with moderate/severe PH was observed in females, but not males (interaction p=0.03). In adjusted analyses, females with moderate/severe PH had an increased hazard of death at 1 year compared with females without PH (adjusted HR 2.14, 95% CI 1.44 to 3.18), whereas those with mild PH did not. Among males, there was no increased hazard of death associated with any severity of PH. In a multivariable Cox model of patients with moderate/severe PH, oxygen-dependent lung disease, inability to perform a 6 min walk, impaired renal function and lower aortic valve mean gradient were independently associated with increased 1-year mortality (p<0.05 for all), whereas several haemodynamic indices were not. A risk score, including these factors, was able to identify patients with a 15% vs 59% 1-year mortality.


CONCLUSIONS
The relationship between moderate/severe PH and increased mortality after TAVR is altered by sex, and clinical factors appear to be more influential in stratifying risk than haemodynamic indices. These findings may have implications for the evaluation of and treatment decisions for patients referred for TAVR with significant PH.


BACKGROUND
NCT00530894.
Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
Brian R
http://orcid.org/0000-0002-6879-5343
BR
Lindman
Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
Alan
A
Zajarias
Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA.
Hersh S
HS
Maniar
Stanford University School of Medicine, Stanford, California, USA.
D Craig
DC
Miller
Mayo Clinic, Rochester, Minnesota, USA.
Rakesh M
RM
Suri
Mid-America Heart Institute, Kansas City, Missouri, USA.
Suzanne V
SV
Arnold
St Paul's Hospital, Vancouver, British Columbia, Canada.
John
J
Webb
Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Lars G
LG
Svensson
Cardiovascular Research Foundation, New York, New York, USA Columbia University Medical Center/New York Presbyterian Hospital, New York, New York, USA.
Susheel
S
Kodali
Cardiovascular Research Foundation, New York, New York, USA.
Ke
K
Xu
Cardiovascular Research Foundation, New York, New York, USA.
Girma M
GM
Ayele
New York Presbyterian Hospital, New York, New York, USA.
Fay
F
Lin
New York Presbyterian Hospital, New York, New York, USA.
Shing-Chiu
SC
Wong
Emory University School of Medicine, Atlanta, Georgia, USA.
Vasilis
V
Babaliaros
Emory University School of Medicine, Atlanta, Georgia, USA.
Vinod H
VH
Thourani
Duke University School of Medicine, Durham, North Carolina, USA.
Pamela S
PS
Douglas
University of Virginia School of Medicine, Charlottesville, Virginia, USA.
Scott
S
Lim
Cardiovascular Research Foundation, New York, New York, USA Columbia University Medical Center/New York Presbyterian Hospital, New York, New York, USA.
Martin B
MB
Leon
Baylor Scott and White Health, Plano, Texas, USA.
Michael J
MJ
Mack
D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000601:surgery*; D002423:Cause of Death / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D008297:Male; D018570:Risk Assessment / Q000379:methods*; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D065467:Transcatheter Aortic Valve Replacement; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology