The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis

Published:October 08, 2022DOI:


      Pulmonary hypertension (PH) frequently co-exists in patients with severe aortic stenosis (AS). In this study, we sought to identify the implications of invasive pulmonary hemodynamics on major adverse cardiac events (MACE), biventricular function and NYHA functional class after transcatheter aortic valve replacement (TAVR).


      Invasive hemodynamics via right heart catheterization (RHC) were performed pre-TAVR. Patients were stratified per mean PA pressure (mPAP), diastolic pulmonary gradient (DPG) and pulmonary vascular resistance (PVR), and followed at 1-month and 1-year intervals up to 6 years. MACE outcomes included cardiovascular death and heart failure hospitalizations post-TAVR.


      Among 215 patients, Kaplan-Meir estimates demonstrated an increased 1-year risk of MACE from 8% among those without pre-TAVR PH to 27% among patients with pre-existing PH. Specifically, the MACE risk was 32% among PH patients with PVR ≥ 3WU (p = .04) and 53% among PH patients with DPG ≥ 7 mm Hg (p < .01). On univariate Cox regression, RV stroke work index (RVSWI) (HR,1.02; p = .02), and pulmonary hemodynamic index (PHI) (HR,1.27; p = .047) were identified as additional predictors of MACE post-TAVR. On multivariable Cox regression analysis, SvO2 (HR, 0.95; p = .01) and PVR (HR, 1.2; p = .04) were demonstrated as predictive of MACE post-TAVR. A significant improvement in LVEF (2-Factor ANOVA, p < .01) and RV fractional area change (RVFAC%) (p < .01) was noted as assessed at baseline, 1-month and 1-year follow up post-TAVR. There was a significant interaction between pre-TAVR PH status and time post procedure with respect to NYHA functional class (p = .03), that is, the manner and degree of change in NYHA class over time depended on pre-TAVR PH status.


      Defining invasive pulmonary hemodynamics, such as mPAP, PVR, and DPG among patients with severe AS undergoing TAVR has significant prognostic implications. Routine risk stratification by utilizing invasive hemodynamics can better identify patients who will have functional improvement and improved outcomes post-TAVR.



      AS (aortic stenosis), PH (pulmonary hypertension), TAVR (transcatheter aortic valve replacement), RHC (right-heart catheterization), MACE (major adverse cardiac event), PVR (pulmonary vascular resistance), DPG (diastolic pulmonary gradient), NYHA (New York Heart Association)
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        • Johnson LW
        • Hapanowicz MB
        • Buonanno C
        • Bowser MA
        • Marvasti MA
        • Parker FB.
        Pulmonary hypertension in isolated aortic stenosis. Hemodynamic correlations and follow-up.
        J Thorac Cardiovasc Surg. 1988; 95: 603-607
        • Opitz CF
        • Hoeper MM
        • Gibbs JSR
        • et al.
        Pre-capillary, combined, and post-capillary pulmonary hypertension: a pathophysiological continuum.
        J Am Coll Cardiol. 2016; 68: 368-378
        • O'Sullivan CJ
        • Wenaweser P
        • Ceylan O
        • et al.
        Effect of pulmonary hypertension hemodynamic presentation on clinical outcomes in patients with severe symptomatic aortic valve stenosis undergoing transcatheter aortic valve implantation: insights from the new proposed pulmonary hypertension classification.
        Circ Cardiovasc Interv. 2015; 8
        • Rosenkranz S
        • Gibbs JSR
        • Wachter R
        • De Marco T
        • Vonk-Noordegraaf A
        • Vachiéry JL.
        Left ventricular heart failure and pulmonary hypertension.
        Eur Heart J. 2016; 37: 942-954
        • Adusumalli S
        • Mazurek JA.
        Pulmonary hypertension due to left ventricular cardiomyopathy: is it the result or cause of disease progression?.
        Curr Heart Fail Rep. 2017; 14: 507-513
        • Roselli EE
        • Abdel Azim A
        • Houghtaling PL
        • Jaber WA
        • Blackstone EH
        Pulmonary hypertension is associated with worse early and late outcomes after aortic valve replacement: implications for transcatheter aortic valve replacement.
        J Thorac Cardiovasc Surg. 2012; 144 (e2): 1067-1074
        • Alushi B
        • Beckhoff F
        • Leistner D
        • et al.
        Pulmonary hypertension in patients with severe aortic stenosis: prognostic impact after transcatheter aortic valve replacement: pulmonary hypertension in patients undergoing TAVR.
        JACC Cardiovasc Imaging. 2019; 12: 591-601
        • Testa L
        • Latib A
        • De Marco F
        • et al.
        Persistence of severe pulmonary hypertension after transcatheter aortic valve replacement: incidence and prognostic impact.
        Circ Cardiovasc Interv. 2016; 9e003563
        • Brunner NW
        • Yue SF
        • Stub D
        • et al.
        The prognostic importance of the diastolic pulmonary gradient, transpulmonary gradient, and pulmonary vascular resistance in patients undergoing transcatheter aortic valve replacement.
        Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2017; 90: 1185-1191
        • Baumgartner H
        • Hung J
        • Bermejo J
        • et al.
        Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.
        J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr. 2017; 30: 372-392
        • Lang RM
        • Badano LP
        • Mor-Avi V
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28 (e14): 1-39
        • Nagueh SF
        • Smiseth OA
        • Appleton CP
        • et al.
        Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the american society of echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr. 2016; 29: 277-314
        • Rudski LG
        • Lai WW
        • Afilalo J
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 685-713
        • Simonneau G
        • Montani D
        • Celermajer DS
        • et al.
        Haemodynamic definitions and updated clinical classification of pulmonary hypertension.
        Eur Respir J. 2019; 531801913
        • Galiè N
        • Humbert M
        • Vachiery JL
        • et al.
        2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS)Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).
        Eur Heart J. 2016; 37: 67-119
        • Gerges C
        • Gerges M
        • Lang MB
        • et al.
        Diastolic pulmonary vascular pressure gradient: a predictor of prognosis in “out-of-proportion” pulmonary hypertension.
        Chest. 2013; 143: 758-766
        • Asami M
        • Stortecky S
        • Praz F
        • et al.
        Prognostic value of right ventricular dysfunction on clinical outcomes after transcatheter aortic valve replacement.
        JACC Cardiovasc Imaging. 2019; 12: 577-587
        • Treibel TA
        • Kozor R
        • Schofield R
        • et al.
        Reverse myocardial remodeling following valve replacement in patients with aortic stenosis.
        J Am Coll Cardiol. 2018; 71: 860-871
        • Dahiya G
        • Kyvernitakis A
        • Joshi AA
        • et al.
        Impact of transcatheter aortic valve replacement on left ventricular hypertrophy, diastolic dysfunction and quality of life in patients with preserved left ventricular function.
        Int J Cardiovasc Imaging. 2021; 37: 485-492
        • Schewel J
        • Schmidt T
        • Kuck KH
        • Frerker C
        • Schewel D.
        Impact of pulmonary hypertension hemodynamic status on long-term outcome after transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2019; 12: 2155-2168
        • Otto CM
        • Nishimura RA
        • Bonow RO
        • et al.
        2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
        Circulation. 2021; 143: e35-e71
        • Weber L
        • Rickli H
        • Haager PK
        • et al.
        Haemodynamic mechanisms and long-term prognostic impact of pulmonary hypertension in patients with severe aortic stenosis undergoing valve replacement.
        Eur J Heart Fail. 2019; 21: 172-181