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Transcatheter Aortic Valve Replacement in Concomitant Aortic Stenosis and Severe Pulmonary Hypertension: Not a Contraindication
Vinod Thourani1, Chun Li1, Dan Gross1, Patrick Kilgo1, Chandan Devireddy1, Bradley G. Leshnower1, Kreton Mavromatis1, Tom C. Nguyen2, Mihir Kanitkar1, Peter C. Block1, Robert A. Guyton1, Amanda L. Maas1, John Merlino1, Stamatios Lerakis1, Vasilis Babaliaros1.
1Emory University, Atlanta, GA, USA, 2University of Texas Medical School Houston, Houston, TX, USA.

OBJECTIVE: Patients with severe aortic stenosis (AS) and concomitant pulmonary hypertension (PHTN) undergoing surgical aortic valve replacement (SAVR) have been shown to have worse outcomes than similar patients without PHTN. Our objectives were to evaluate the prevalence of PHTN in patients undergoing transcatheter aortic valve replacement (TAVR), characterize patient risk for PHTN, evaluate the post-operative trajectory of PHTN, and assess its longitudinal effects on post-operative outcomes.
METHODS: A retrospective review of all patients undergoing TAVR from September 2007 to May 2013 was performed. PHTN was determined by echocardiographic reading of right ventricular systolic pressure (RVSP). Patients were categorized by the degree of preexisting PHTN: severe (>50mmHg, n=137), moderate (35-50mmHg, n=129) and mild/none(<35mmHg, n=90). Only patients with both pre- and post-operative echocardiographic data were included. Generalized estimating equations (GEE) were used to estimate the trajectory of post-operative PHTN levels, adjusting for preoperative PHTN and age. Kaplan-Meier survival curves and Cox Proportional hazards regression (with adjusted hazard ratios) was used to estimate the effect of preoperative PHTN on long-term survival.
RESULTS: A total of 356 patients with complete echocardiographic data were analyzed. Mean ages in years: severe 81.3±7.7, moderate 82.3±7.7, and mild 82.1±7.7 (p=0.29). Moderate to severe mitral/tricuspid regurgitation increased sequentially across the three PHTN groups: 11%, 28%, 43% (56/130) for mitral and 7%, 20%, 46% for tricuspid. Post-operatively, there were no differences in adverse outcomes including death (2.2%, 3.1%, 4.4%, p=0.66) and stroke (3.3%, 3.9%, 0.0%, p=0.07). Also, long-term survival was equivalent among the three groups in unadjusted analysis (p=0.18) and adjusted Cox analysis (p=0.28). In-hospital mortality was 3.4% for all groups despite a mean STS PROM score of 12.4%. In GEE analysis, severity of PHTN did not increase or decrease from pre-operative levels following surgery (p=0.85), nor was there any interaction between baseline PHTN and time (p=0.57).
CONCLUSIONS: Unlike in SAVR where severity of PHTN appears to play a large role in postoperative outcomes, severe pulmonary HTN should not preclude patients from receiving TAVR.

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