Skip to main content

Advertisement

SpringerLink
Log in

Prognostic value of mild-to-moderate pulmonary hypertension in patients with severe aortic valve stenosis undergoing aortic valve replacement

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

Abstract

Background

Optimal timing of elective aortic valve replacement (AVR) for severe aortic stenosis (AS) is challenging. Hence, a sensitive marker in AS patients indicating increasing risk after AVR would be of great clinical value. In the present study, we hypothesized that mild-to-moderate pulmonary hypertension (PH) assessed prior to AVR is a sensitive marker for adverse events in patients after successful AVR.

Methods

We enrolled 200 consecutive patients with severe AS undergoing AVR. Among them, 176 patients (88%) were symptomatic. Patients were divided according to systolic pulmonary artery pressure (PAPsys) into three groups: no PH (PAPsys <30 mmHg), mild-to-moderate PH (PAPsys ≥30 and PAPsys <60 mmHg) and severe PH (≥60 mmHg). Multivariable analyses were adjusted for age and gender and included PH, left ventricular ejection fraction ≤35%, renal insufficiency and logistic EuroSCORE ≥20%. Primary endpoint was death of any cause within 5 years after AVR.

Results

During follow-up, 23 patients died (cumulative 5-year mortality rate 14.6%). Patients without (n = 78), mild-to-moderate (n = 99) and severe PH (n = 23) had 5-year mortality rates of 2.6, 15.2 and 26.1% (p = 0.001). PAPsys ≥30 mmHg yielded an excellent level of sensitivity of 92.8%. On multivariable analysis, mild-to-moderate PH was the only independent risk factor (hazard ratio 4.9, 95% confidence interval 1.1–21.8).

Conclusions

In patients with severe AS undergoing AVR, mild-to-moderate PH is a strong and independent predictor of late mortality. Conversely, patients with normal PAPsys have an extremely good prognosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS (2008) 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the society of cardiovascular anesthesiologists, society for cardiovascular angiography and interventions, and society of thoracic surgeons. J Am Coll Cardiol 52(13):e1–e142. doi:10.1016/j.jacc.2008.05.007

    Google Scholar 

  2. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S (2010) Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 363(17):1597–1607. doi:10.1056/NEJMoa1008232

    Article  PubMed  CAS  Google Scholar 

  3. Nowicki ER, Birkmeyer NJ, Weintraub RW, Leavitt BJ, Sanders JH, Dacey LJ, Clough RA, Quinn RD, Charlesworth DC, Sisto DA, Uhlig PN, Olmstead EM, O’Connor GT (2004) Multivariable prediction of in-hospital mortality associated with aortic and mitral valve surgery in Northern New England. Ann Thorac Surg 77(6):1966–1977. doi:10.1016/j.athoracsur.2003.12.035

    Article  PubMed  Google Scholar 

  4. Kolh P, Kerzmann A, Honore C, Comte L, Limet R (2007) Aortic valve surgery in octogenarians: predictive factors for operative and long-term results. Eur J Cardiothorac Surg 31(4):600–606. doi:10.1016/j.ejcts.2007.01.003

    Article  PubMed  Google Scholar 

  5. Connolly HM, Oh JK, Schaff HV, Roger VL, Osborn SL, Hodge DO, Tajik AJ (2000) Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction: result of aortic valve replacement in 52 patients. Circulation 101(16):1940–1946

    PubMed  CAS  Google Scholar 

  6. Aragam JR, Folland ED, Lapsley D, Sharma S, Khuri SF, Sharma GV (1992) Cause and impact of pulmonary hypertension in isolated aortic stenosis on operative mortality for aortic valve replacement in men. Am J Cardiol 69(16):1365–1367

    Article  PubMed  CAS  Google Scholar 

  7. Riegel N, Ambrose JA, Mindich BP, Fuster V (1985) Isolated aortic stenosis with severe pulmonary hypertension. Cathet Cardiovasc Diagn 11(2):181–185

    Article  PubMed  CAS  Google Scholar 

  8. Lipkin DP, Poole-Wilson PA (1986) Symptoms limiting exercise in chronic heart failure. Br Med J (Clin Res Ed) 292(6527):1030–1031

    Article  CAS  Google Scholar 

  9. Gorlin R, Dexter L (1952) Hydraulic formula for the calculation of the cross-sectional area of the mitral valve during regurgitation. Am Heart J 43(2):188–205

    Article  PubMed  CAS  Google Scholar 

  10. Ben-Dor I, Goldstein SA, Pichard AD, Satler LF, Maluenda G, Li Y, Syed AI, Gonzalez MA, Gaglia MA Jr, Wakabayashi K, Delhaye C, Belle L, Wang Z, Collins SD, Torguson R, Okubagzi P, Aderotoye A, Xue Z, Suddath WO, Kent KM, Epstein SE, Lindsay J, Waksman R (2011) Clinical profile, prognostic implication, and response to treatment of pulmonary hypertension in patients with severe aortic stenosis. Am J Cardiol 107(7):1046–1051. doi:10.1016/j.amjcard.2010.11.031

    Article  PubMed  Google Scholar 

  11. Tracy GP, Proctor MS, Hizny CS (1990) Reversibility of pulmonary artery hypertension in aortic stenosis after aortic valve replacement. Ann Thorac Surg 50(1):89–93

    Article  PubMed  CAS  Google Scholar 

  12. Gault JH (1975) Angiographic estimation of left ventricular volume. Cathet Cardiovasc Diagn 1(1):7–16

    Article  PubMed  CAS  Google Scholar 

  13. Roques F, Michel P, Goldstone AR, Nashef SA (2003) The logistic EuroSCORE. Eur Heart J 24(9):881–882. S0195668X02007996 [pii]

    Article  PubMed  CAS  Google Scholar 

  14. Efron B, Tibshirani R (1993) An introduction to the bootstrap: monographs on statistics and applied probability. Chapman and Hall, London

    Google Scholar 

  15. Johnson LW, Hapanowicz MB, Buonanno C, Bowser MA, Marvasti MA, Parker FB Jr (1988) Pulmonary hypertension in isolated aortic stenosis. Hemodynamic correlations and follow-up. J Thorac Cardiovasc Surg 95(4):603–607

    PubMed  CAS  Google Scholar 

  16. Kapoor N, Varadarajan P, Pai RG (2008) Echocardiographic predictors of pulmonary hypertension in patients with severe aortic stenosis. Eur J Echocardiogr 9(1):31–33. doi:10.1016/j.euje.2007.01.005

    PubMed  Google Scholar 

  17. Faggiano P, Frattini S, Zilioli V, Rossi A, Nistri S, Dini FL, Lorusso R, Tomasi C, Cas LD (2011) Prevalence of comorbidities and associated cardiac diseases in patients with valve aortic stenosis. Potential implications for the decision-making process. Int J Cardiol. doi:10.1016/j.ijcard.2011.02.026

  18. Malouf JF, Enriquez-Sarano M, Pellikka PA, Oh JK, Bailey KR, Chandrasekaran K, Mullany CJ, Tajik AJ (2002) Severe pulmonary hypertension in patients with severe aortic valve stenosis: clinical profile and prognostic implications. J Am Coll Cardiol 40(4):789–795. pii: S0735109702020028

    Article  PubMed  Google Scholar 

  19. Cam A, Goel SS, Agarwal S, Menon V, Svensson LG, Tuzcu EM, Kapadia SR (2011) Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis. J Thorac Cardiovasc Surg. doi:10.1016/j.jtcvs.2010.12.024

  20. Delgado JF, Conde E, Sanchez V, Lopez-Rios F, Gomez-Sanchez MA, Escribano P, Sotelo T, Gomez de la Camara A, Cortina J, de la Calzada CS (2005) Pulmonary vascular remodeling in pulmonary hypertension due to chronic heart failure. Eur J Heart Fail 7(6):1011–1016. doi:10.1016/j.ejheart.2004.10.021

    Article  PubMed  Google Scholar 

  21. Moraes DL, Colucci WS, Givertz MM (2000) Secondary pulmonary hypertension in chronic heart failure: the role of the endothelium in pathophysiology and management. Circulation 102(14):1718–1723

    PubMed  CAS  Google Scholar 

  22. Silver K, Aurigemma G, Krendel S, Barry N, Ockene I, Alpert J (1993) Pulmonary artery hypertension in severe aortic stenosis: incidence and mechanism. Am Heart J 125(1):146–150

    Article  PubMed  CAS  Google Scholar 

  23. Badesch DB, Champion HC, Sanchez MA, Hoeper MM, Loyd JE, Manes A, McGoon M, Naeije R, Olschewski H, Oudiz RJ, Torbicki A (2009) Diagnosis and assessment of pulmonary arterial hypertension. J Am Coll Cardiol 54(1 Suppl):S55–S66. doi:10.1016/j.jacc.2009.04.011

    Article  PubMed  Google Scholar 

  24. Copeland JG, Griepp RB, Stinson EB, Shumway NE (1977) Isolated aortic valve replacement in patients older than 65 years. JAMA 237(15):1578–1581

    Article  PubMed  CAS  Google Scholar 

  25. Carnero-Alcazar M, Reguillo-Lacruz F, Alswies A, Villagran-Medinilla E, Maroto-Castellanos LC, Rodriguez-Hernandez J (2010) Short- and mid-term results for aortic valve replacement in octogenarians. Interact Cardiovasc Thorac Surg 10(4):549–554. doi:10.1510/icvts.2009.218040

    Article  PubMed  Google Scholar 

  26. Kirsh MM, Orvald T, Preston T, Kahn D (1970) Pulmonary hypertension–a complication of aortic valve disease. Mich Med 69(1):33–35

    PubMed  CAS  Google Scholar 

  27. Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C, Baudet E, Cortina J, David M, Faichney A, Gabrielle F, Gams E, Harjula A, Jones MT, Pintor PP, Salamon R, Thulin L (1999) Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 15(6):816–822; discussion 822–833. pii: S1010794099001062

    Google Scholar 

  28. Nashef SA, Roques F (2002) Risk assessment, league tables, and report cards: where is true quality monitoring? Ann Thorac Surg 74(5):1748–1749; author reply 1749

    Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Innere Medizin III, Kardiologie und Herz-/Kreislauferkrankungen, Eberhard-Karls-Universität Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany

    Christine S. Zuern, Christian Eick, Konstantinos Rizas, Cosmina Stoleriu, Barbara Woernle, Christian Herdeg, Meinrad Gawaz & Axel Bauer

  2. Thorax-, Herz- und Gefäßchirurgie, Eberhard-Karls-Universität Tübingen, Tübingen, Germany

    Stephen Wildhirt & Ulrich Stock

Authors
  1. Christine S. Zuern
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christian Eick
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Konstantinos Rizas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cosmina Stoleriu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Barbara Woernle
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stephen Wildhirt
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Christian Herdeg
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ulrich Stock
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Meinrad Gawaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Axel Bauer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Axel Bauer.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Zuern, C.S., Eick, C., Rizas, K. et al. Prognostic value of mild-to-moderate pulmonary hypertension in patients with severe aortic valve stenosis undergoing aortic valve replacement. Clin Res Cardiol 101, 81–88 (2012). https://doi.org/10.1007/s00392-011-0367-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-011-0367-3

Keywords

Search

Navigation