Abstract 17006: Right Ventricular - Pulmonary Vascular Coupling and Mortality in Patients with Severe Aortic Stenosis Referred for Transcatheter Aortic Valve Replacement
Background: Pulmonary hypertension (PH) is associated with increased mortality in patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The prevalence of pre-capillary PH and right ventricular (RV) dysfunction in high-risk patients with severe AS referred for transcatheter AVR (TAVR) has not been examined, but could have important clinical implications.
Methods: Data were prospectively collected on 121 patients with severe AS (AVA index <0.6 cm2/m2) referred for TAVR. PH was defined as invasive mPAP ≥25 mmHg and classified passive (PVR <2.5 WU) or reactive (PVR ≥2.5). RV dysfunction = tricuspid annular plane systolic excursion (TAPSE) < 13mm. A Cox proportional hazards all-cause mortality model adjusted for age, sex, EF, and AVR (TAVR or surgical) and separately evaluated mPAP, RV dysfunction, and TAPSE/mPAP. F/u = 15±12 months.
Results: The mean age was 83 years, AVA 0.62 cm2, EF 53%, and 52% were female. PH was present in 66% of subjects and associated with worse 1-year survival: 85%, 77%, 72%, and 49% for no, mild, moderate, and severe PH, respectively (p=0.02). RV dysfunction was present in 49% and associated with increased unadjusted mortality (HR 2.06, CI 1.01-4.21, p=0.048), but not adjusted mortality. Increased mPAP (HR 1.04, CI 1.01-1.07) and decreased TAPSE/mPAP (HR 4.8, CI 1.1-21.6) were associated with increased adjusted mortality. Passive PH was present in 28% and reactive PH in 37% of the total cohort. Compared to passive PH, reactive PH was associated with an increased mPAP (39±9 vs. 30±5, p<0.001) and PVR (4.6±2.4 vs. 1.6±0.6, p<0.001), decreased cardiac index (2.2±0.5 vs. 2.7±0.6, p<0.001) and PA compliance and a trend toward more RV dysfunction (70% vs. 48%, p=0.08), but no difference in wedge, AS severity, LVEF, or FEV1.
Conclusions: In patients with severe AS referred for TAVR, the severity of PH and a parameter coupling RV function and pulmonary afterload are predictors of increased mortality. A pre-capillary contribution to PH is common and associated with an adverse hemodynamic profile. Further studies are needed to examine RV-pulmonary vascular coupling in these patients as there may be important implications for survival, symptomatic improvement after AVR, and a potential role for adjunctive medical therapy.
- © 2012 by American Heart Association, Inc.