Pulmonary artery hypertension in severe aortic stenosis: Incidence and mechanism

Objective: Severe aortic stenosis leads to increased pulmonary arterial systolic pressure. A controversy still remains regarding the impact of persistent pulmonary hypertension (PHT) on prognosis of patients undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the impact of persistent PHT on 2-year all-cause mortality of patients with severe aortic stenosis following TAVI. Methods: Patients with severe and symptomatic aortic stenosis (effective orifice area [EOA]≤1 cm 2 ) who were scheduled for TAVI with a self-expanding valve at our institution were prospectively enrolled. Prospectively collected echocardiographic data before and after TAVI were retrospectively analyzed in all patients. Pulmonary artery systolic pressure was estimated as the sum of the right ventricular to the right atrial gradient during systole and the right atrial pressure. PHT following TAVI was classified as absent if <35 mmHg and persistent if ≥35 mmHg. Primary clinical end-point was 2-year all-cause mortality defined according to the criteria proposed by the Valve Academic Research Consortium-2. Results: Hundred and forty patients (mean age: 82±9 years) were included in the study. The primary clinical end point occurred in 17 patients (12%) during a median follow-up period of 2 years. Mean pulmonary artery systolic pressure was reduced in all patients following TAVI (45±9 versus 41±6 mmHg, p<0.01). Mortality rate was higher in patients with persistent PHT compared to patients with normal pulmonary artery systolic pressure following TAVI (26% versus 14 %, p<0.01). Patients that reached the primary clinical end point had a higher post procedural mean systolic pulmonary pressure (43±9 versus 39±6 mmHg, p=0.02). In multivariate regression analysis, persistence of PHT (OR: 2.51, 95% CI: 1.109-7.224, p=0.01) was an independent predictor of long-term mortality. Conclusions: The persistence of pulmonary hypertension after TAVI is associated with long term mortality. Identifying the population that will clearly benefit from TAVI is still need to be validated by larger trials.

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E/Ea is the Major Determinant of Pulmonary Artery Pressure in Moderate to Severe Aortic Stenosis

Journal of the American Society of Echocardiography ◽

10.1016/j.echo.2007.12.002 ◽

2008 ◽

Vol 21 (7) ◽

pp. 824-827 ◽

Cited By ~ 33

Author(s):

Grace Casaclang-Verzosa ◽

Vuyisile T. Nkomo ◽

Maurice E. Sarano ◽

Joseph F. Malouf ◽

Fletcher A. Miller ◽

...

Keyword(s):

Aortic Stenosis ◽

Pulmonary Artery ◽

Pulmonary Artery Pressure ◽

Severe Aortic Stenosis ◽

Major Determinant ◽

Artery Pressure

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“Pure” severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features

The International Journal of Cardiovascular Imaging ◽

10.1007/s10554-020-01907-4 ◽

2020 ◽

Vol 36 (10) ◽

pp. 1917-1929

Author(s):

J. Kandels ◽

B. Tayal ◽

A. Hagendorff ◽

D. Lavall ◽

U. Laufs ◽

...

Keyword(s):

Aortic Stenosis ◽

Heart Diseases ◽

Severe Aortic Stenosis ◽

Diagnostic Algorithm ◽

Pulmonary Artery Hypertension ◽

Left Ventricular ◽

Low Flow ◽

Effective Orifice Area ◽

Valvular Heart Diseases ◽

Mean Pressure

Abstract Purpose In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPGAV) and transvalvular flow velocity (maxVAV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with “pure” severe AS. Methods and Results Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) “pure” severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm2 were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPGAV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with “pure” severe AS showed mean mPGAV of 31.7 ± 9.1 mmHg and mean maxVAV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPGAV > 40 mmHg and maxVAV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of “pure” AS patients exhibited all three alterations. Ranges of mPGAV and maxVAV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients’ treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156). Conclusion In patients with “pure” AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.

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Arrhythmogenic Risk of Pulmonary Artery Catheterisation in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

Survey of Anesthesiology ◽

10.1097/01.sa.0000460940.95490.0e ◽

2015 ◽

Vol 59 (2) ◽

pp. 62

Author(s):

L. Bergmann ◽

T. Growendt ◽

P. Kahlert ◽

T. Konorza ◽

D. Wendt ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Pulmonary Artery ◽

Transcatheter Aortic Valve Implantation ◽

Severe Aortic Stenosis ◽

Transcatheter Aortic Valve ◽

Pulmonary Artery Catheterisation ◽

Aortic Valve Implantation ◽

Valve Implantation

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A case of severe aortic stenosis: ongoing challenges with management

Challenging Concepts in Congenital and Acquired Heart Disease in the Young ◽

10.1093/med/9780198759447.003.0002 ◽

2020 ◽

pp. 13-28

Author(s):

Sok-Leng Kang ◽

Robin Martin

Keyword(s):

Aortic Stenosis ◽

Pulmonary Artery ◽

Severe Aortic Stenosis ◽

Treatment Options ◽

Clinical Signs ◽

Signs And Symptoms ◽

Ross Procedure ◽

Intervention Treatment ◽

Pulmonary Conduit ◽

Clinical Signs And Symptoms

The clinical management of severe aortic stenosis in the newborn period is complex and challenging. This chapter presents case of severe aortic stenosis in a 3-day-old neonate who required multiple interventions in infancy, including balloon aortic valvuloplasty, the Ross procedure, pulmonary conduit replacement, and branch pulmonary artery stenting. The chapter outlines the clinical signs and symptoms of aortic stenosis in neonates, detailed echocardiographic and haemodynamic assessment of the morphology and severity of the lesion, and indications for intervention. Treatment options and the evidence surrounding each are also explored. Ultimately, the optimal treatment strategy and timing of intervention are likely to depend on local expertise and clinical condition at presentation.

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