Pulmonary hypertension is associated with worse early and late outcomes after aortic valve replacement: Implications for transcatheter aortic valve replacement

Objectives: Our objectives were to determine the prevalence of pulmonary hypertension (PHT) in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis (AS), characterize risk for PHT, assess changes in PHT, and analyze its effect on outcomes. Methods: From January 1996 to July 2010, a total of 4372 patients with severe AS underwent primary AVR. Right ventricular systolic pressure (RVSP), a surrogate for PHT, was estimated echocardiographically in 2385, the study group. Preoperative RVSP was less than 35 mm Hg (low pressure) in 611, 35 to 50 mm Hg (moderate PHT) in 1199, and greater than 50 mm Hg (high PHT) in 575. From active follow-up, 10,218 patient-years were available for survival analysis and 3716 echocardiograms after AVR for assessing RVSP. Results: Median preoperative RVSP was 41 mm Hg (range, 10-104 mm Hg). Older, more symptomatic female patients with more comorbidities and tricuspid or mitral regurgitation had higher RVSP. Hospital mortality was higher in those with higher RVSP (0.9% low presssure, 1.9% moderate PHT, 3.1% high PHT, P = .03), as was risk of renal (P < .0001) or respiratory failure (P < .0001), sepsis (P = .01), and prolonged hospitalization (P < .0001). Initial post-AVR RVSP improvement was not maintained but rose to preoperative levels by 3 to 4 years. Long-term survival was worse in patients with higher RVSP (P < .0001): 85% and 63% low pressure; 77% and 45% moderate PHT; and 62% and 31% high PHT at 5 and 10 years, respectively. Conclusions: Most patients undergoing primary AVR have at least moderate PHT that is not relieved by AVR; its severity is associated with mortality, serious complications, and worse late survival. PHT severity should be included in risk assessment before aortic valve intervention. These outcomes suggest that earlier intervention for AS warrants further study. (J Thorac Cardiovasc Surg 2012;144:1067-74)