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J Thorac Cardiovasc Surg 2011;142:800-808
© 2011 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis

^a Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
^b Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
^c Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio

Received for publication August 25, 2010; revisions received November 12, 2010; accepted for publication December 16, 2010.

^_* Address for reprints: Samir R. Kapadia, MD, Professor of Medicine, Director, Cardiac Catheterization Laboratory, 9500 Euclid Ave, Desk J2-31, Cleveland, OH 44195. (Email: kapadis{at}ccf.org).

Objective: We sought to determine the clinical outcomes of patients undergoing surgical aortic valve replacement with hemodynamically confirmed severe pulmonary hypertension and aortic stenosis and compare them with the outcomes of patients not undergoing aortic valve replacement and patients undergoing aortic valve replacement with mild-to-moderate pulmonary hypertension.

Methods: A total of 317 patients with severe aortic stenosis (aortic valve area < 1 cm²) underwent right heart catheterization along with left heart catheterization between 2004 and 2009. Severe pulmonary hypertension (mean pulmonary artery pressure > 35 mm Hg) was present in 81 patients, of whom 35 (43.2%) underwent surgical aortic valve replacement. We compared the clinical outcomes of these 35 patients with the 46 patients with severe pulmonary hypertension who did not undergo surgical aortic valve replacement.

Results: Thirty-day mortality after aortic valve replacement was 2.85% in patients with severe pulmonary hypertension and 10.86% in patients not undergoing aortic valve replacement (P = .001). During a mean follow-up of 339.0 ± 343.7 days, overall mortality in patients undergoing aortic valve replacement was 14.2% in patients with severe pulmonary hypertension and 50% in patients with severe pulmonary hypertension who did not undergo aortic valve replacement (P < .0001). On the other hand, among patients who underwent surgery, overall mortality was similar in both the mild-to-moderate pulmonary hypertension group (23 patients [20.3%]) and the severe pulmonary hypertension group at the end of the follow-up period (P = .4). In a multivariate analysis, the presence of chronic obstructive pulmonary disease and the lack of reduction in mean pulmonary artery pressure were independent predictors of mortality in these high-risk patients undergoing aortic valve replacement, whereas baseline mean pulmonary artery pressure was not a predictor. Preoperative pulmonary capillary wedge pressure was a significant predictor of postoperative reduction in mean pulmonary artery pressure.

Conclusions: In patients with severe aortic stenosis and severe pulmonary hypertension who undergo aortic valve replacement, baseline pulmonary artery pressure does not unfavorably affect survival. Aortic valve replacement should be considered for patients with aortic stenosis with severe pulmonary hypertension, especially with higher pulmonary capillary wedge pressure.

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