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Impact of Severe Pulmonary Hypertension on Outcomes Late After Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation
Luminita Iliuta.
University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.

OBJECTIVE: 1. To evaluate the effect of aortic valve replacement (AVR) on pulmonary hypertension (PH) evolution, comparing patients with aortic stenosis (AS) to patients with aortic regurgitation (AR) 2. To determine whether PH remains a risk factor in the modern era for adverse outcomes after AVR for AS compared to AR. 3. To assess the independent predictors for persistence of the severe PH late after AVR.
METHODS: 5 years prospective study on 197 patients with severe PH undergoing AVR for AS (82pts) or AR (115pts)who were evaluated clinically and echocardiographically (including TDI) preoperatively and at 10 days, 1, 3, 6 months, 1 year and yearly 5 years postoperatively. Statistical analysis used SYSTAT and SPSS programs for regression analysis and relative risk calculations. Multivariable analyses were adjusted for age and gender and included left ventricular ejection fraction ≤35%, renal insufficiency and logistic EuroSCORE ≥20%. Primary endpoint was death of any cause within 5 years after AVR.
RESULTS: 1. The evolution of the PH was different in AS group (early after AVR PH improved) compared with AR group. At 1 year postoperatively the percent of the patients with persistent severe PH was 21.95% in AS group and 56.52% in AR group. 2. At 5 years, cardiovascular event-free survival, including hospital visits caused by heart failure symptoms and sudden cardiac death was significantly higher in the patients with preoperative AS (59,76 %) compared with AR group (30,44%). 3. Regression analysis identified as independent predictors for persistence of PH late after AVR: preoperative AR (RR=21.2), E/E'ratio>12 (RR=25.1), LA dimension index>30mm/m2 (RR=8.2, p=0.0017), LV enddiastolic volume(LVEDV)>200cm3 (RR=8.6), obstructive pulmonary disease(RR=28.6), smoking (RR=18.7) and 2 degree mitral regurgitstion (MR) (RR=12.6).
CONCLUSIONS: 1. Severe PH is reversible mostly after AVR for AS than for AR, both in the early and late postoperative term. 2. The presence of severe PH had a significant impact on outcomes in patients undergoing AVR, decreasing long-term survival and increasing hospitalizations rates, mostly in those with preoperative AR. 3. The main predictors for persistence of severe PH late after AVR were: preoperative AR, E/E'>12, LVEDV>200cm3, LA dimension index>30mm/m2, obstructive pulmonary disease, smoking and associated 2 degree MR.

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