Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis

Insights into calcific aortic valve stenosis: a comprehensive overview of the disease and advancing treatment strategies

Aortic valve stenosis is a disease characterized by thickening and narrowing of the aortic valve (AV), most commonly due to calcification, which leads to left ventricular outflow obstruction called calcific aortic valve disease (CAVD). CAVD presents as a progressive clinical syndrome with cardiorespiratory symptoms, often with rapid deterioration. The modern-day pathophysiology of CAVD involves a complex interplay of genetic factors, chronic inflammation, lipid deposition, and valve calcification, with early CAVD stages resembling atherosclerosis. Various imaging modalities have been used to evaluate CAVD, with a recent trend of using advanced imaging to measure numerous AV parameters, such as peak jet velocity. Significant improvements in mortality have been achieved with transcatheter AV repair, but numerous therapeutics and modalities are being researched to delay the progression of CAVD. This article aims to provide a comprehensive review of CAVD, explore recent developments, and provide insights into future treatments with various novel modalities.

Post-Capillary Pulmonary Hypertension: Clinical Review

Pulmonary hypertension (PH) caused by left heart disease, also known as post-capillary PH, is the most common etiology of PH. Left heart disease due to systolic dysfunction or heart failure with preserved ejection fraction, valvular heart disease, and left atrial myopathy due to atrial fibrillation are causes of post-capillary PH. Elevated left-sided filling pressures cause pulmonary venous congestion due to backward transmission of pressures and post-capillary PH. In advanced left-sided heart disease or valvular heart disease, chronic uncontrolled venous congestion may lead to remodeling of the pulmonary arterial system, causing combined pre-capillary and post-capillary PH. The hemodynamic definition of post-capillary PH includes a mean pulmonary arterial pressure > 20 mmHg, pulmonary vascular resistance < 3 Wood units, and pulmonary capillary wedge pressure > 15 mmHg. Echocardiography is important in the identification and management of the underlying cause of post-capillary PH. Management of post-capillary PH is focused on the treatment of the underlying condition. Strategies are geared towards pharmacotherapy and guideline-directed medical therapy for heart failure, surgical or percutaneous management of valvular disorders, and control of modifiable risk factors and comorbid conditions. Referral to centers with advanced heart and pulmonary teams has shown to improve morbidity and mortality. There is emerging interest in the use of targeted agents classically used in pulmonary arterial hypertension, but current data remain limited and conflicting. This review aims to serve as a comprehensive summary of postcapillary PH and its etiologies, pathophysiology, diagnosis, and management, particularly as it pertains to advanced heart failure.

Impact of pulmonary hypertension on short-term outcomes in patients undergoing surgical aortic valve replacement for severe aortic valve stenosis

OBJECTIVES

In patients with left heart disease and severe aortic stenosis (AS), pulmonary hypertension (PH) is a common comorbidity and predictor of poor prognosis. Untreated AS aggravates PH leading to an increased right ventricular afterload and, in line to right ventricular dysfunction. The surgical benefit of aortic valve replacement (AVR) in elderly patients with severe AS and PH could be limited due to the multiple comorbidities and poor outcomes. Therefore, we purposed to investigate the impact of PH on short-term outcomes in patients with moderate to severe AS who underwent surgical AVR in our heart center.

METHODS

In this study we retrospectively analyzed a cohort of 99 patients with severe secondary post-capillary PH who underwent surgical AVR (AVR + PH group) at our heart center between 2010 and 2021 with a regard to perioperative outcomes. In order to investigate the impact of PH on short-term outcomes, the control group of 99 patients without pulmonary hypertension who underwent surgical AVR (AVR group) at our heart center with similar risk profile was accordingly analyzed regarding pre-, intra- and postoperative data.

RESULTS

Atrial fibrillation occurred significantly more often (p = .013) in patients who suffered from PH undergoing AVR. In addition, the risk for cardiac surgery (EUROSCORE II) was significantly higher (p < .001) in the above-mentioned group. Likewise, cardiopulmonary bypass time (p = .018), aortic cross-clamp time (p = .008) and average operation time (p = .009) were significantly longer in the AVR + PH group. Furthermore, the in-hospital survival rate was significantly higher (p = .044) in the AVR group compared to the AVR + PH group. Moreover, the dialysis rate was significantly higher (p < .001) postoperatively in patients who suffered PH compared to the patients without PH undergoing AVR.

CONCLUSION

In our study, patients with severe PH and severe symptomatic AS who underwent surgical aortic valve replacement showed adverse short-term outcomes compared to patients without PH.

Impact of left ventricular end-diastolic pressure as a marker for diastolic dysfunction on long-term outcomes in patients undergoing transcatheter aortic valve replacement

OBJECTIVE

The aim of this study was to investigate the proportion of elevated left ventricular end-diastolic pressure (LVEDP) as an indicator of diastolic function after transcatheter aortic valve replacement (TAVR) and its implication in predicting long-term mortality.

METHODS

We analyzed retrospectively collected data on 3328 patients with severe aortic stenosis undergoing TAVR in our institution between July 2009 and June 2021. Patients were stratified into two groups based on invasive post-procedural LVEDP measurements: normal (<15 mmHg) vs. elevated (≥15 mmHg) LVEDP.

RESULTS

Mean age of the patients was 81.6 years, and 53.3% were female. Elevated post-procedural LVEDP was identified in 2408 (72.3%) patients. The 5-year mortality rates were higher in the group with elevated LVEDP compared with the group with normal LVEDP (27.4% vs. 8.3%, p = 0.01; hazard ratio [HR] 1.22, 95% CI 1.05-1.41). A multivariate model revealed the following independent predictors of mortality after TAVR: post-procedural elevated LVEDP (HR 1.24, 95% CI 1.01-1.53), pre-procedural significant tricuspid regurgitation (HR 1.24, 95% CI 1.02-1.52) and pulmonary hypertension (PH) (HR 1.53, 95% CI 1.26-1.86). In the present study, a significant paravalvular leak after TAVR was not associated with higher mortality (HR 1.45, 95% CI-0.95-2.19, p = 0.75).

CONCLUSION

Elevated post-procedural LVEDP in patients who undergo TAVR is an independent predictor of all-cause mortality. Furthermore, PH and tricuspid regurgitation were also identified as predictors of mortality. These data confirm that diastolic dysfunction is an important predictor of mortality in TAVR and should be considered to guide procedure timing, favoring an early interventional approach and management in aortic stenosis patients.

[Pulmonary hypertension associated with left heart disease (group 2)]

Pulmonary hypertension associated with left heart disease (PH-LHD) corresponds to group two of pulmonary hypertension according to clinical classification. Haemodynamically, this group includes isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH). PH-LHD is defined by an mPAP > 20 mmHg and a PAWP > 15 mmHg, pulmonary vascular resistance (PVR) with a cut-off value of 2 Wood Units (WU) is used to differentiate between IpcPH and CpcPH. A PVR greater than 5 WU indicates a dominant precapillary component. PH-LHD is the most common form of pulmonary hypertension, the leading cause being left heart failure with preserved (HFpEF) or reduced ejection fraction (HFmrEF, HFrEF), valvular heart disease and, less commonly, congenital heart disease. The presence of pulmonary hypertension is associated with increased symptom burden and poorer outcome across the spectrum of left heart disease. Differentiating between group 1 pulmonary hypertension with cardiac comorbidities and PH-LHD, especially due to HFpEF, is a particular challenge. Therapeutically, no general recommendation for the use of PDE5 inhibitors in HFpEF-associated CpcPH can be made at this time. There is currently no reliable rationale for the use of PAH drugs in IpcPH, nor is therapy with endothelin receptor antagonists or prostacyclin analogues recommended for all forms of PH-LHD.

Prevalence of pulmonary hypertension in aortic stenosis and its influence on outcomes

OBJECTIVE

The significance of pulmonary hypertension (PHT) complicating aortic stenosis (AS) is poorly characterised. In a large cohort of adults with at least moderate AS, we aimed to describe the prevalence and prognostic importance of PHT in such patients.

METHODS

In this retrospective study, we analysed the National Echocardiography Database of Australia (data from 2000 to 2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater AS were included (n=14 980). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 2.6 years, IQR 1.0-4.6 years).

RESULTS

Subjects were aged 77±13 years and 57.4% were female. Overall, 2049 (13.7%), 5085 (33.9%), 4380 (29.3%), 1956 (13.1%) and 1510 (10.1%) patients had no (eRVSP<30.00 mm Hg), borderline (30.00-39.99 mm Hg), mild (40.00-49.99 mm Hg), moderate (50.00-59.99 mm Hg) and severe PHT (>60.00 mm Hg), respectively. An echocardiographic phenotype was evident with worsening PHT, showing rising E:e' ratio and right and left atrial sizes(p<0.0001, for all). Adjusted analyses showed that the risk of long-term mortality progressively rose as eRVSP level increased (HR 1.14-2.94, borderline to severe PHT, p<0.0001 for all). A mortality threshold was identified in the 4th decile of eRVSP categories (35.01-38.00 mm Hg; HR 1.19, 95% CI 1.04 to 1.35), with risk progressively increasing through to the 10th decile (HR 2.86, 95% CI 2.54 to 3.21).

CONCLUSIONS

In this large cohort study, we find that PHT is common in ≥moderate AS and mortality increases as PHT becomes more severe. A threshold for higher mortality lies within the range of 'borderline-mild' PHT.

TRIAL REGISTRATION NUMBER

ACTRN12617001387314.

Association Between Pulmonary Hypertension and Its Effect on 30-Day Mortality, Readmission, and Cost After Transcatheter Aortic Valve Replacement: A Multicenter Study

Background Pulmonary hypertension (PH) is commonly seen in patients with severe aortic stenosis. Transcatheter aortic valve replacement (TAVR) has been shown to improve PH, however, its impact on clinical outcomes and cost remains unclear. Methods We did a multicenter, retrospective analysis of patients undergoing TAVR in our system between December 2012 to November 2020. The initial sample size was 1356. We excluded patients with prior history of heart failure, with a left ventricular ejection fraction of 40% or less, and patients who had active symptoms of heart failure within two weeks of the procedure. Patients were divided into four groups based on their pulmonary pressures, using right ventricular systolic pressure (RVSP) as a surrogate for PH. Groups included patients with normal pulmonary pressures (<35mmHg), mild (35-45mmHg) moderate (46-60mmHg), and severe PH (>60mmHg). Primary outcomes included 30-day mortality and readmission. Secondary outcomes included length of ICU stay and cost of admission. We used Chi-square and T-tests for demographic analysis of categorical continuous variables respectively. Adjusted regression was used for the reliability of correlation between variables. Multivariate analysis was used for final outcomes. Results Final sample size was 474. Average age was 78.9 years (SD: 8.2, 53% Male). Thirty-one percent (n=150) had normal pulmonary pressures, 33% (n=156) had mild PH, 25% (n=122) had moderate and 10% (n=46) had severe PH. Patients with history of hypertension (p-value<0.001), diabetes (p-value<0.001), chronic lung disease (p-value=0.006) and those on supplemental oxygen (p-value=0.046), had significantly higher proportion of patients with moderate and severe PH. We found significantly higher odds of 30-day mortality in patients with severe PH (OR: 6.77, CI: 1.09-41.98: p-value 0.04) compared with normal or mild PH. There was no significant difference in 30-day readmission (p-value=0.859) between the four groups. Cost did not change with severity of PH (Avg: $261,075: p-value=0.810). Patients with severe PH spent a significantly higher number of hours in ICU, compared with the other three groups (Mean: 18.2, p=value <0.001). Conclusions Severe pulmonary hypertension significantly increased the odds of 30-day mortality and ICU stay in TAVR patients. We did not see any significant difference in 30-day readmission and cost of admission, based on PH severity.

Favorable Prognosis in Patients with Recovered Pulmonary Hypertension after TAVI: An Analysis of the LAPLACE-TAVI Registry

Pulmonary hypertension (PH) is a common complication of aortic stenosis (AS). Despite the established association between PH and poor outcomes in patients with AS, the prognostic implication of a change in PH after transcatheter aortic valve implantation (TAVI) has been rarely evaluated. This study analyzed a prospective multi-center TAVI registry database involving six Japanese centers and used the transtricuspid pressure gradient (TRPG) obtained by echocardiography to estimate pulmonary artery systolic pressure. The participants (n = 2056) were first divided into two groups by TRPG before TAVI, a PH (−) group (TRPG < 30 mmHg) (n = 1407, 61.9%) and a PH (+) group (TRPG ≥ 30 mmHg) (n = 649, 28.6%). Next, by TRPG after (4.1 ± 5.3 days) TAVI, the PH (+) group was further subdivided into two groups, Recovered PH (TRPG < 30 mmHg, n = 253) and Persistent PH (TRPG after TAVI ≥ 30 mmHg, n = 396). The median follow-up duration was 1.8 years. The primary and secondary endpoints were the composite and each of cardiovascular (CV) death and heart failure hospitalization, respectively. Unadjusted Kaplan-Meier estimates with log-rank comparisons showed significantly higher cumulative incidences of primary and secondary endpoints in the Persistent PH group compared to other groups. Moreover, adjusted multivariate Cox-proportional hazard analyses showed that a decreased (−10 mmHg) TRPG after TAVI was linearly associated with a reduced risk of the primary endpoint (hazard ratio (HR): 0.76, 95% confidence interval (CI): 0.64−0.90, p = 0.0020). The findings in the present study indicate that the recovery of PH may partly contributes to the prognostic benefit of TAVI procedure in patients with AS and elevated pulmonary artery systolic pressure.

Application of a Novel Two-Dimensional Echocardiographic Calcium Quantification Method to Assess All Severities of Aortic Stenosis

BACKGROUND

Aortic valve (AV) calcification (AVC) is a strong predictor of aortic stenosis (AS) severity. The two-dimensional AVC (2D-AVC) ratio, a gain-independent ratio composed of the average pixel density of the AV and the aortic annulus, has previously shown strong correlations with two-dimensional (2D) echocardiographic hemodynamic parameters for severe AS and AVC by cardiac computed tomography. We hypothesize that the 2D-AVC ratio correlates with hemodynamic parameters in all severities of AS.

METHODS

A total of 285 patients with a normal AV (n = 49), aortic sclerosis (n = 75), or mild (n = 38), moderate (n = 72), or severe (n = 51) AS undergoing 2D echocardiography were retrospectively evaluated, and the 2D-AVC ratios were correlated to mean AV gradient, peak AV velocity, AV area, and dimensionless index. The 2D-AVC ratios of various AS severities were compared against each other via area under the curve (AUC) analysis.

RESULTS

The 2D-AVC ratio is strongly correlated with mean AV gradient (r = 0.79, P < .0001) and peak AV velocity (r = 0.78, P < .0001). There was moderate correlation with the AV area (r = -0.58, P < .0001) and dimensionless index (r = -0.67, P < .0001) across all AS severities. The 2D-AVC ratio also distinguished nonmoderate AS (mild AS + normal AV) from moderate or greater (moderate + severe) AS (AUC = 0.93) and moderate versus severe AS (AUC = 0.88).

CONCLUSION

The 2D-AVC ratio exhibits moderate to strong correlation with 2D echocardiographic hemodynamic parameters across all severities of AS.

The impact of frailty on adverse outcomes after transcatheter aortic valve replacement in older adults: A retrospective cohort study

Background

Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement for patients who are at increased surgical risk. Consequently, frailty is common in patients undergoing TAVR.

Objectives

This study aims to investigate the impact of frailty on outcomes following TAVR.

Methods

A retrospective cohort study was conducted, including all TAVR candidates who visited the geriatric outpatient clinic for preoperative screening. Frailty status was assessed according to the Groningen Frailty Indicator. The primary outcome of the study was defined as the occurrence of postoperative complications, and this was evaluated according to the Clavien–Dindo classification. An additional analysis was performed to assess the impact of frailty on 1‐year all‐cause mortality and complications within 30 days of TAVR according to the Valve Academic Research Consortium (VARC‐2) criteria. The VARC‐2 criteria provide harmonized endpoint definitions for TAVR studies.

Results

In total, 431 patients with a mean age of 80.8 ± 6.2 years were included, of whom 56% were female. Frailty was present in 36% of the participants. Frailty was associated with a higher risk of the composite outcome of complications [adjusted odds ratio (OR): 1.55 (95% confidence interval, CI: 1.03–2.34)], 30‐day mortality [adjusted OR: 4.84 (95% CI: 1.62–14.49)], 3‐month mortality [adjusted OR: 2.52 (95% CI: 1.00–6.28)] and 1‐year mortality [adjusted OR: 2.96 (95% CI: 1.46–6.00)].

Conclusions

Frailty is common in TAVR patients and is associated with an increased overall risk of postoperative complications, particularly mortality. Increased optimization of screening and treatment of frailty in the guidelines for valvular heart diseases is recommended.

Clinical impact of mitral regurgitation in aortic valve stenosis: Insight from effective regurgitant orifice area

PURPOSE

Mechanisms leading to heart failure (HF) symptoms in aortic valve stenosis (AS) are contentious. We examined the impact of secondary mitral regurgitation (MR) on the symptomatic status in patients with AS.

METHODS

Outpatients performing echocardiography with any degree of AS, without organic mitral valve disease, mitral valve intervention, or aortic insufficiency were enrolled. MR was quantitatively defined through mitral effective regurgitant orifice area (EROA) using the proximal isovelocity surface area method. Patients were divided into two groups (New York Heart Association [NYHA] class I-II vs. NYHA class III-IV).

RESULTS

Five hundred and eighty-four patients were enrolled (484 NYHA I-II, 100 NYHA III-IV). More symptomatic patients had smaller aortic valve area (AVA), lower left ventricular ejection fraction (LVEF) and stroke volume, higher E/E', and LV global afterload. MR was present in 178 (30%) patients and EROA was <.20 cm² in 158 (89%). NYHA III-IV patients showed higher prevalence of MR (78% vs 21%, P < 0.0001) and larger EROA (.13±.08 cm² vs .09±.07 cm² , P < 0.0001). An association between EROA and symptoms was present in the total cohort and in subgroups with preserved LVEF, AVA ≥ 1 and <1 cm² , EE' 8-14 and ≥14 (P < 0.05 for all). EROA was associated with severe symptoms after adjustment for LVEF, E/E', and AVA in the overall population (OR 1.10 [1.06-1.15]; P < 0.0001) and in the 516 patients with preserved LVEF (OR 1.13 [1.08-1.19]; P < 0.0001).

CONCLUSION

In patients with AS, greater EROA values are associated with HF symptoms, even though MR degree is far from the threshold of MR severity. Therefore, even a mild MR represents a supportive marker of HF symptoms presence.

Determinants of changes in pulmonary artery pressure in patients with severe aortic stenosis treated by transcatheter aortic valve implantation

BACKGROUND

Elevated pulmonary artery pressure (PAP) in patients with severe aortic stenosis (AS) is a strong predictor of adverse prognosis. This study sought to assess the relation between PAP and clinical and echocardiographic parameters in elderly patients with severe AS, as well as to identify the determinants of the change in PAP after transcatheter aortic valve implantation (TAVI).

METHODS

The study included 170 subjects (age 81 ± 7 years, 45% men) with symptomatic severe AS who were treated by TAVI. They underwent a clinical evaluation and a transthoracic echocardiography before the TAVI procedure and 6 months after.

RESULTS

In a multivariable analysis, the independent predictors for baseline PAP were the body mass index (BMI) (β = 0.21, p = .006), COPD GOLD class (β = 0.20; p = .009), the E/e' ratio (β = 0.20; p = .02) and the degree of aortic regurgitation (β = 0.20; p = .01). After TAVI, there was significantly less (51% vs. 29%, p<.0001) pulmonary hypertension, defined as a tricuspid regurgitation velocity ≥2.8 m/s. The baseline variables related to an improvement in PAP were the tricuspid regurgitation velocity (p = .0001) and the E/e' (p = .005). From the parameters potentially modified with TAVI, the only independent predictor of PAP variation was the change in the E/e' ratio (β = 0.23; p = .01).

CONCLUSIONS

Independent predictors for baseline PAP in elderly patients with symptomatic AS were the BMI, GOLD class, the aortic regurgitation and the E/e' ratio. The baseline predictors for a change in PAP 6 months after TAVI were the baseline PAP and E/e', with only the change in the E/e' ratio being correlated to the change in PAP.

The influence of cardiac valvular calcification on all-cause and cardiovascular mortality in maintenance hemodialysis patients

OBJECTIVE

To investigate the effect of cardiac valve calcification (CVC) on all-cause and cardiovascular mortality in maintenance hemodialysis (MHD) patients.

METHODS

A retrospective cohort study was conducted in 183 long-term hemodialysis patients with complete follow-up data from January 1, 2012, to December 30, 2015. The baseline data between CVC and non-CVC groups were compared. Kaplan-Meier method was used to analyze all-cause and cardiovascular mortality. The effect of CVC on prognosis was analyzed using the Cox proportional hazard regression model and subgroup analysis.

RESULTS

Among 183 patients under hemodialysis, 104 (56.8%) were males, with an average age of 56.1 ± 17.0 years and 68 (37.2%) were complicated with valvular calcification. The median follow-up period was 30.8 months. All-cause and cardiovascular mortality were 50% vs. 14.8% and 25% vs. 7.0% in the CVC and non-CVC groups, respectively (P < 0.05). Kaplan-Meier indicated that differences in all-cause and cardiovascular mortality were statistically significant between the two groups (P < 0.001). Cox regression analysis showed that CVC significantly increased all-cause (hazards ratio [HR] 2.161 [1.083-4.315]) and cardiovascular mortality (3.435 [1.222-9.651]) after adjusting for multiple factors. Meanwhile, CVC also increases the incidence of new-onset cardiovascular events. Subgroup analysis revealed that all-cause and cardiovascular mortality were significantly higher in patients with aortic valve calcification (AVC) than in patients with mitral valve calcification (MVC). Multivariate calibration showed that AVC increased the risk of cardiovascular death (HR 5.486 [1.802-16.702]) (P < 0.05), whereas MVC did not. By further comparing the echocardiographic data of the two groups, the incidence of LVH and pulmonary hypertension in the AVC group was significantly higher than that in the MVC group.

CONCLUSION

Valve calcification increases the risk of all-cause and cardiovascular mortality in MHD patients, also new-onset cardiovascular events, and aortic valve calcification contributes more to the risk of cardiovascular mortality.

Aortic valve replacement with pulmonary hypertension: Meta-analysis of 70 676 patients

BACKGROUND AND AIM OF THE STUDY

We compared early and late outcomes of surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) and pulmonary hypertension (PHT).

METHODS

We searched MEDLINE and EMBASE databases until July 2018 for studies comparing patients with AS and none, mild-moderate, or severe PHT undergoing SAVR. Random-effects meta-analysis was performed.

RESULTS

There were 12 observational studies with 70 676 patients with median follow-up 4.0 years (interquartile range, 2.6-4 years). Compared to patients with no PHT, patients with any PHT undergoing SAVR were older (mean difference [MD], 2.31 years; 95% confidence interval [CI], 1.38-3.23 years; P < .01), with greater comorbidities and reduced ejection fraction (MD, -4.36; 95%CI, -5.94 to -2.78; P < .01). Patients with any PHT had higher unadjusted (5.2% vs 2.4%; risk ratio [RR], 2.27; 95%CI, 2.04-2.53; P < .01) and adjusted (RR, 1.65; 95%CI, 1.28-2.14; P < .01) in-hospital mortality compared with no PHT. Severe (RR, 3.53; 95%CI, 1.46-8.54; P < .01) and mild-moderate PHT (RR, 2.13; 95%CI, 1.28-3.55; P < .01) were associated with higher unadjusted in-hospital mortality compared with no PHT. Any PHT was associated with a higher unadjusted risk of stroke (RR, 1.64; 95%CI, 1.42-1.90; P < .01), acute kidney injury (RR, 2.02; 95%CI, 1.50-2.72; P < .01), prolonged ventilation (RR, 1.62; 95%CI, 1.04-2.52; P = .03), and longer hospital stay (MD, 1.76 days; 95%CI, 0.57-2.95; P < .01). Severe (HR, 2.44; 95%CI, 1.60-3.72; P < .01) but not mild-moderate PHT (HR, 2.25; 95%CI, 0.91-5.59; P = .08) was associated with higher adjusted long-term mortality compared with no PHT.

CONCLUSIONS

Patients with severe AS and severe PHT had a significant increase in operative mortality and more than double the risk of long-term mortality following SAVR compared with patients with no PHT. Such patients may benefit from a less invasive transcatheter aortic valve intervention.

Pulmonary hypertension and valvular heart disease

Pulmonary hypertension (PH) is an important contributor to morbidity and mortality in patients with left-sided heart disease, including valvular heart disease. In this context, elevated left atrial pressure primarily leads to the development of post-capillary PH. Despite the fact that repair of left-sided valvular heart disease by surgical or interventional approaches will improve PH, recent studies have highlighted that PH (pre- or post-interventional) remains an important predictor of long-term outcome. Here, we review the current knowledge on PH in valvular heart disease taking into account new hemodynamic PH definitions, and the distinction between post- and pre-capillary components of PH. A specific focus is on the precise characterization of hemodynamics and cardiopulmonary interaction, and on potential strategies for the management of residual PH after mitral or aortic valve interventions. In addition, we highlight the clinical significance of tricuspid regurgitation, which may occur as a primary condition or as a consequence of PH and right heart dilatation (functional). In this context, proper patient selection for potential tricuspid valve interventions is crucial. Finally, the article highlights gaps in evidence, and points toward future perspectives.

Left Ventricular Morphology and Function as a Determinant of Pulmonary Hypertension in Patients with Severe Aortic Stenosis: Cardiovascular Magnetic Resonance Imaging Study

Background and Objectives: The influence of cardiac magnetic resonance (CMR) derived left ventricular (LV) parameters on the prognosis of patients with aortic stenosis (AS) was analyzed in several studies. However, the data on the relations between the LV parameters and the development of pulmonary hypertension (PH) in severe AS is lacking. Our objectives were to evaluate the CMR-derived changes of the LV size, morphology, and function in patients with isolated severe AS and PH, and to investigate the prognostic impact of these parameters on elevated systolic pulmonary artery pressure (sPAP). Materials and Methods: Thirty patients with isolated severe AS (aortic valve area ≤1 cm²) underwent a 2D-echocardiography (2D echo) and CMR before aortic valve replacement. Indices of the LV mass and volumes and ejection fraction were analyzed by CMR. The LV global longitudinal (LV LGS) and circumferential strain (LV CS) were calculated using CMR feature tracking (CMR-FT) software (Medis Suite QStrain 2.0, Medis Medical Imaging Systems B.V., Leiden, The Netherlands). The LV fibrosis expansion was assessed using a late gadolinium enhancement sequence. PH was defined as having an estimated sPAP of ≥45 mm Hg. The statistical analysis as performed using SPSS version 23.0 (SPSS, Chicago, IL, USA) Results: 30 patients with severe AS were included in the study, 23% with severe isolated AS had PH (mean sPAP 55 ± 6.6 mm Hg). More severe LV anatomical and functional abnormalities were observed in patients with PH when compared with patients without PH-a higher LV end-diastolic volume index (EDVi) (140 [120.0-160.0] vs. 90.0 mL/m² [82.5-103.0], p = 0.04), larger LV fibrosis area (7.8 [5.6-8.0] vs. 1.3% [1.2-1.5], p = 0.005), as well as lower LV global longitudinal strain (GLS; -14.0 [-14.9-(-8.9)] vs. -21.1% [-23.4-(-17.8)], p = 0.004). By receiver-operating characteristic (ROC) curve analysis, LV EDVi > 107.7 mL/m² (Area Under the Curve (AUC) 95.7%), LV GLS < -15.5% (AUC 86.3%), and LV fibrosis area >5% (AUC 89.3) were found to be robust predictors of PH in severe AS patients. Conclusions: In patients with severe aortic stenosis, a larger end-diastolic LV volume, impaired LV global longitudinal strain, and larger LV fibrosis extent can predict the development of pulmonary hypertension.

Characterization of biventricular alterations in myocardial (reverse) remodelling in aortic banding-induced chronic pressure overload

Aortic Stenosis (AS) is the most frequent valvulopathy in the western world. Traditionally aortic valve replacement (AVR) has been recommended immediately after the onset of heart failure (HF) symptoms. However, recent evidence suggests that AVR outcome can be improved if performed earlier. After AVR, the process of left ventricle (LV) reverse remodelling (RR) is variable and frequently incomplete. In this study, we aimed at detecting mechanism underlying the process of LV RR regarding myocardial structural, functional and molecular changes before the onset of HF symptoms. Wistar-Han rats were subjected to 7-weeks of ascending aortic-banding followed by a 2-week period of debanding to resemble AS-induced LV remodelling and the early events of AVR-induced RR, respectively. This resulted in 3 groups: Sham (n = 10), Banding (Ba, n = 15) and Debanding (Deb, n = 10). Concentric hypertrophy and diastolic dysfunction (DD) were patent in the Ba group. Aortic-debanding induced RR, which promoted LV functional recovery, while cardiac structure did not normalise. Cardiac parameters of RV dysfunction, assessed by echocardiography and at the cardiomyocyte level prevailed altered after debanding. After debanding, these alterations were accompanied by persistent changes in pathways associated to myocardial hypertrophy, fibrosis and LV inflammation. Aortic banding induced pulmonary arterial wall thickness to increase and correlates negatively with effort intolerance and positively with E/e′ and left atrial area. We described dysregulated pathways in LV and RV remodelling and RR after AVR. Importantly we showed important RV-side effects of aortic constriction, highlighting the impact that LV-reverse remodelling has on both ventricles.

Impact of Left Ventricular Diastolic Dysfunction and Biomarkers on Pulmonary Hypertension in Patients with Severe Aortic Stenosis

Background: Severe aortic stenosis (AS) complicated by pulmonary hypertension (PH) is associated with poor outcomes after surgical aortic valve replacement (AVR). There is still scarce information about predictors of secondary PH in this group of patients. Objectives: The aim of this study was to investigate the prognostic impact of biomarkers together with conventional Doppler echocardiographic parameters of left ventricular diastolic function on elevated pulmonary systolic pressure (PSP) in severe AS patients before surgical AVR. Methods: Sixty patients with severe isolated AS (aortic valve area <1 cm²) underwent echocardiography, N-terminal pro B-type natriuretic peptide (NT-proBNP) and growth differentiation factor-15 (GDF-15) measurements before AVR. PSP, left ventricular ejection fraction (LV EF), parameters of LV diastolic function (E/E’ ratio, mitral valve deceleration time (MV DT) and left atrial (LA) volume) were evaluated. PH was defined as an estimated PSP ≥ 45 mmHg. Results: Of the 60 patients, 21.7% with severe isolated AS had PH with PSP ≥ 45 mmHg (58.5 ± 11.2 mmHg). LV EF did not differ between groups and was not related to an elevated PSP (50 ± 8 vs. 49 ± 8%, p = 0.58). Parameters of LV diastolic dysfunction (E/E’ ratio > 14 (OR 6.00; 95% CI, 1.41–25.48; p = 0.009), MV DT ≤ 177.5 ms (OR 9.31; 95% CI, 2.06–41.14; p = 0.001), LA volume > 100 mL (OR 9.70; 95% CI, 1.92–49.03; p = 0.002)) and biomarkers (NT-proBNP > 4060 ng/L (OR 12.54; 95% CI, 2.80–55.99; p < 0.001) and GDF-15 > 3393 pg/mL (OR 18.33; 95% CI, 2.39–140.39; p = 0.001)) were significantly associated with elevated PSP in severe AS. Conclusions: Left ventricular diastolic dysfunction and elevated biomarkers levels could predict the development of pulmonary hypertension in patients with severe aortic stenosis. Elevation of biomarkers paired with worsening of LV diastolic dysfunction could help to stratify patients for earlier surgical treatment before the development of pulmonary hypertension.

Pulmonary hypertension associated with left heart disease: Updated Recommendations of the Cologne Consensus Conference 2018

In the summer of 2016, delegates from the German Society of Cardiology (DGK), the German Respiratory Society (DGP), and the German Society of Pediatric Cardiology (DGPK) met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary hypertension (PH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines, aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to PH associated with left heart disease. In this context, the European Guidelines point out that the drugs currently approved to treat patients with PAH (prostanoids, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, sGC stimulators) have not sufficiently been investigated in other forms of PH. However, despite the lack of respective efficacy data, an uncritical use of targeted PAH drugs in patients with PH associated with left heart disease is currently observed at an increasing rate. This development is a matter of concern. On the other hand, PH is a frequent problem that is highly relevant for morbidity and mortality in patients with left heart disease. In that sense, the distinction between isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH) and their proper definition may be of particular relevance. The detailed results and recommendations of the working group on PH associated with left heart disease, which were last updated in the spring of 2018, are summarized in this article.

The Right Heart-Pulmonary Circulation Unit and Left Heart Valve Disease

Valvular heart disease (VHD) is frequently accompanied by pulmonary hypertension (PH). In asymptomatic patients, PH is rare, although the exact prevalence is unknown and mainly stems from the severity of the VHD and the presence of diastolic dysfunction. PH can also be depicted during exercise echocardiography. PH either at rest or during exercise is also a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology. Therefore, because PH is a marker of poor prognosis, assessment of PH in VHD is crucial for risk stratification and management of patients with VHD.

Left atrial dysfunction as a determinant of pulmonary hypertension in patients with severe aortic stenosis and preserved left ventricular ejection fraction

In patients with severe aortic stenosis (AS), the presence of pulmonary hypertension (PH) has been linked to a poor prognosis. We aimed to assess the main determinants of PH in patients with severe AS and preserved left ventricular ejection fraction (LVEF). We prospectively enrolled 108 consecutive patients with isolated severe AS (indexed aortic valve area <0.6 cm²/m²) and LVEF >50%, in sinus rhythm. Left atrial (LA) function was assessed using longitudinal deformation parameters (by speckle tracking echocardiography). PH (defined as systolic pulmonary artery pressure >40 mmHg) was present in 20 patients. Patients with severe AS and PH were older (p = 0.05), had higher BNP values (p = 0.05) and a greater degree of LV diastolic dysfunction: higher E/e' and E/A ratios and lower EDT values (p < 0.03 for all) compared to patients without PH. There were no differences between groups regarding AS severity and LV systolic function parameters. Patients with PH had a more impaired LA function: lower septal and lateral late diastolic peak velocity a' (p < 0.001 and p = 0.04 respectively) and lower LA peak longitudinal strain and strain rate parameters (p ≤ 0.005 for all). In multivariable analysis, LA late diastolic longitudinal strain rate was the only independent correlate of PH in our patients (p = 0.04). Patients with isolated severe AS, preserved LVEF and PH had larger LA volumes, a more impaired LA function, and higher LV filling pressures compared to those without PH. LA booster pump function, reflected by late diastolic longitudinal strain rate, emerged as an independent correlate of PH in these patients.

Increased mortality from complications of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement

Aortic stenosis (AS) leads to pulmonary hypertension (PH) and right ventricle (RV) failure. Our goal was to describe mortality related to postoperative complications in PH patients undergoing transcatheter aortic valve replacement (TAVR). Ninety-three TAVR patients were analyzed (controls, sPAP < 50 mmHg; cases, sPAP ≥ 50 mmHg). Significant findings in cases included increased mortality (365 days), post-TAVR atrioventricular block (AVB) and acute kidney injury (AKI), and increased mean length of stay (LOS). This novel study highlights complications of PH as independent risk factors for death and significant morbidity post TAVR. Optimization of preoperative volume status and RV afterload reduction, while addressing AVB and AKI, may play a vital role in reducing mortality and LOS.

Epidemiology of Pulmonary Hypertension in Left Heart Disease

Pulmonary hypertension (PH) in the setting of left side heart disease is associated with adverse outcomes. The exact prevalence of PH in the different pathologies that affect the left ventricle, however, is difficult to access with the current literature. The lack of a standard definition of PH in older studies, the different modalities to assess pulmonary artery pressures and the varying disease severity, all account for the great variability in the reported prevalence of PH. PH can accompany heart failure (HF) with reduced (HFrEF) or preserved ejection fraction (HFpEF) as well as mitral and aortic valve disease; in any of these instances it is important to recognize whether the elevation of pulmonary pressures is driven by elevated left ventricular pressures only (isolated post-capillary PH) or if there is an accompanying remodeling component in the pulmonary arterioles (combined post-capillary and pre-capillary PH). The objective of this review is to describe the definitions, prevalence and the risk factors associated with the development of PH in the setting of HFrEF, HFpEF and valvular heart disease.

Pulmonary Hypertension in Aortic Stenosis and Mitral Regurgitation: Rest and Exercise Echocardiography Significance

Valvular heart disease is a common cause of increased mean pulmonary artery pressure (PAP). Aortic stenosis and mitral regurgitation are frequently accompanied by pulmonary hypertension (PH), especially when they are severe and symptomatic. In asymptomatic patients, PH is rare, though the exact prevalence is unknown and mainly stems from the severity of the valvular heart disease and the presence of diastolic dysfunction. Exercise echocardiography has recently gained interest in depicting PH. In these asymptomatic patients, exercise PH is observed in about >40%. Either PH at rest (systolic PAP >50 mmHg) or during exercise (systolic PAP >60 mmHg) is a powerful determinant of outcome and is independently associated with reduced survival, regardless of the severity of the underlying valvular pathology.

Multimorbidity in Older Adults with Aortic Stenosis

Aortic stenosis is a disease of older adults; many have associated comorbidities. With the aging of the population and the emergence of transcatheter aortic valve replacement as a treatment, clinicians will increasingly be confronted with aortic stenosis and multimorbidity, making the evaluation, management, and treatment of aortic stenosis more complex. To optimize patient-centered clinical outcomes, new treatment paradigms are needed that recognize the import and influence of multimorbidity on patients with aortic stenosis. The authors review the prevalence of medical and aging-related comorbidities in patients with aortic stenosis, their impact on outcomes, and discuss how they influence management and treatment decisions.

Pulmonary hypertension is a manifestation of congestive heart failure and left ventricular diastolic dysfunction in octogenarians with severe aortic stenosis

Previous studies have suggested that pulmonary hypertension (PH) in severe aortic stenosis (AS) is a risk factor for operative mortality with aortic valve replacement (AVR). Conversely, others have shown that patients with AS and PH extract a large symptomatic and survival benefit from AVR compared with those patients not treated surgically. We sought to evaluate the prevalence, severity, and mechanism of PH in an elderly patient cohort with severe AS. We prospectively evaluated 41 patients aged ≥80 years with severe AS. All patients underwent cardiac catheterization and transthoracic echocardiography within 24 hours. We found that PH was common in this cohort: 32 patients (78%) had PH; however, the predominant mechanism of PH was left heart congestion. Patients with PH had nearly double the pulmonary artery wedge pressure of patients without PH (23 vs. 13 mmHg; P ≤ 0.001). In patients with PH compared with those without, pulmonary vascular resistance was higher yet still under 3 Wood units (WU; 2.9 vs. 1.5 WU; P = 0.001), and the transpulmonary gradient (11 vs. 7 mmHg; P = 0.01) and diastolic pulmonary gradient (DPG; 3.0 vs. 2.7 mmHg; P = 0.74) were in normal range. Left ventricular diastolic abnormalities were more common in patients with severe AS and PH. Right ventricular (RV) dysfunction was common (13/41 patients, 32%), but the PH and non-PH groups had similar tricuspid annular plane systolic excursion (2.0 vs. 2.3 cm; P = 0.15). Only 2 subjects had both RV dysfunction and an elevated DPG. In conclusion, PH is common in elderly patients with severe AS. This occurs largely due to left heart congestion, with a relative absence of pulmonary vascular disease and RV dysfunction, and as such, PH may serve as a heart failure equivalent in these patients.

Risk stratification in patients with pulmonary hypertension undergoing transcatheter aortic valve replacement

OBJECTIVE

Pulmonary hypertension (PH) is associated with increased mortality after surgical or transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS), and when the pulmonary artery pressure is particularly elevated, there may be questions about the clinical benefit of TAVR. We aimed to identify clinical and haemodynamic factors associated with increased mortality after TAVR among those with moderate/severe PH.

METHODS

Among patients with symptomatic AS at high or prohibitive surgical risk receiving TAVR in the Placement of Aortic Transcatheter Valves (PARTNER) I randomised trial or registry, 2180 patients with an invasive measurement of mean pulmonary artery pressure (mPAP) recorded were included, and moderate/severe PH was defined as an mPAP ≥35 mm Hg.

RESULTS

Increasing severity of PH was associated with progressively worse 1-year all-cause mortality: none (n=785, 18.6%), mild (n=838, 22.7%) and moderate/severe (n=557, 25.0%) (p=0.01). The increased hazard of mortality associated with moderate/severe PH was observed in females, but not males (interaction p=0.03). In adjusted analyses, females with moderate/severe PH had an increased hazard of death at 1 year compared with females without PH (adjusted HR 2.14, 95% CI 1.44 to 3.18), whereas those with mild PH did not. Among males, there was no increased hazard of death associated with any severity of PH. In a multivariable Cox model of patients with moderate/severe PH, oxygen-dependent lung disease, inability to perform a 6 min walk, impaired renal function and lower aortic valve mean gradient were independently associated with increased 1-year mortality (p<0.05 for all), whereas several haemodynamic indices were not. A risk score, including these factors, was able to identify patients with a 15% vs 59% 1-year mortality.

CONCLUSIONS

The relationship between moderate/severe PH and increased mortality after TAVR is altered by sex, and clinical factors appear to be more influential in stratifying risk than haemodynamic indices. These findings may have implications for the evaluation of and treatment decisions for patients referred for TAVR with significant PH.

TRIAL REGISTRATION

NCT00530894.

Emerging hemodynamic signatures of the right heart (Third International Right Heart Failure Summit, part 2)

Despite the importance of preserved right ventricular structure and function with respect to outcome across the spectrum of lung, cardiac, and pulmonary vascular diseases, only recently have organized efforts developed to consider the pulmonary vascular-right ventricular apparatus as a specific unit within the larger context of cardiopulmonary pathophysiology. The Third International Right Heart Failure Summit (Boston, MA) was a multidisciplinary event dedicated to promoting a dialogue about the scientific and clinical basis of right heart disease. The current review provides a synopsis of key discussions presented during the section of the summit titled "Emerging Hemodynamic Signatures of the Right Heart." Specifically, topics emphasized in this element of the symposium included (1) the effects of pulmonary vascular dysfunction at rest or provoked by exercise on the right ventricular pressure-volume relationship, (2) the role of pressure-volume loop analysis as a method to characterize right ventricular inefficiency and predict right heart failure, and (3) the importance of a systems biology approach to identifying novel factors that contribute to pathophenotypes associated with pulmonary arterial hypertension and/or right ventricular dysfunction. Collectively, these concepts frame a forward-thinking paradigm shift in the approach to right heart disease by emphasizing factors that regulate the transition from adaptive to maladaptive right ventricular-pulmonary vascular (patho)physiology.

Prognostic impact of pulmonary artery systolic pressure in patients undergoing transcatheter aortic valve replacement for aortic stenosis

Baseline pulmonary hypertension (PH) is a predictor of poor outcomes in patients with severe aortic stenosis (AS). Surgical aortic valve replacement is thought to alleviate PH. The aim of this study was to determine the prognostic impact of PH in patients who underwent transcatheter aortic valve replacement (TAVR). An observational cohort study was conducted using prospectively collected data on 277 consecutive patients with severe AS who underwent TAVR at the Mayo Clinic (Rochester, Minnesota) from November 1, 2008, to June 31, 2013. Clinical and echocardiographic data, pulmonary function characteristics, and outcomes stratified by tertiles of pulmonary artery systolic pressure (PASP) were analyzed. From 277 patients who underwent TAVR, 251 patients had PASP assessment at baseline. Those in the highest PASP tertile (PASP ≥49 mm Hg) had more severe chronic lung disease and worse diastolic dysfunction. Being in the highest PASP tertile was an independent predictor of long-term mortality (hazard ratio 2.88, 95% confidence interval 1.15 to 7.23). Patients in the highest PASP tertile had longer lengths of hospital stay, while other short-term outcomes (30-day mortality and readmission, stroke, prolonged ventilation, and reoperation for bleeding) were similar across PASP tertiles. TAVR was associated with a decrease in PASP in the highest PASP tertile at 1 week after the procedure (-8 ± 14 mm Hg) and at 3 months (-7 ± 15 mm Hg) compared with baseline. In conclusion, among patients with severe AS who underwent TAVR, higher baseline PASP was strongly associated with diastolic dysfunction and chronic lung disease. Patients with higher baseline PASP tolerated TAVR relatively well in the early postprocedural phase, with diminished long-term survival. PH should not disqualify patients with severe AS from consideration for TAVR.

Saudi Guidelines on the Diagnosis and Treatment of Pulmonary Hypertension: Pulmonary hypertension due to left heart disease

Pulmonary hypertension (PH) due to left heart disease is the most common cause of pulmonary hypertension in the western world. It is classified as WHO PH group II. Different pathophysiologic abnormalities may take place in this condition, including pulmonary venous congestion and vascular remodeling. Despite the high prevalence of WHO group 2 PH, the major focus of research on PH over the past decade has been on WHO group 1 pulmonary arterial hypertension (PAH). Few investigators have focused on WHO group 2 PH; consequently, the pathophysiology of this condition remains poorly understood, and no specific therapy is available. Clinical and translational studies in this area are much needed and have the potential to positively affect large numbers of patients. In this review, we provide a detailed discussion upon the pathophysiology of the disease, the recent updates in classification, and the diagnostic and therapeutic algorithms.

Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: study from the FRANCE 2 Registry

BACKGROUND

Pulmonary hypertension (PH) is associated with poor prognosis in patients with severe aortic stenosis. The aim of this multicenter study was to describe clinical outcome after transcatheter aortic valve implantation.

METHODS AND RESULTS

The FRANCE 2 Registry included all patients undergoing transcatheter aortic valve implantation in France in 2010 and 2011. Patients were divided into 3 groups depending on systolic pulmonary artery pressure (sPAP) estimated in transthoracic echocardiography: group I, sPAP <40 mm Hg (no PH); group II, sPAP 40 to 59 mm Hg (mild-to-moderate PH); and group III, sPAP ≥60 mm Hg (severe PH). Patients were followed up for 1 year. A total of 2435 patients whose pre-transcatheter aortic valve implantation sPAP was reported were included. A total of 845 were in group I (34.7%), 1112 in group II (45.7%), and 478 in group III (19.6%). Procedural success, early complications, and 30-day mortality were statistically similar across sPAP groups. One-year mortality was higher in groups II and III (group I, 22%; group II, 28%; and group III, 28%; P=0.032). Mild-to-moderate and severe PH were identified as an independent factor of all-cause mortality. The major adverse cardiovascular event rates did not differ according to sPAP. New York Health Association functional class improved significantly in all groups.

CONCLUSIONS

PH (sPAP ≥40 mm Hg) in patients with aortic stenosis undergoing transcatheter aortic valve implantation was associated with increased 1-year mortality especially when severe (sPAP ≥60 mm Hg) but not with increased 30-day mortality, and functional status was significantly improved regardless of PAP level.

Effect of preoperative pulmonary hypertension on outcomes in patients with severe aortic stenosis following surgical aortic valve replacement

Pulmonary hypertension (PH) is prevalent in patients with aortic stenosis (AS); however, previous studies have demonstrated inconsistent results regarding the association of PH with adverse outcomes after aortic valve replacement (AVR). The goal of this study was to evaluate the effects of preoperative PH on outcomes after AVR. We performed a regional prospective cohort study using the Northern New England Cardiovascular Disease Study Group database to identify 1,116 consecutive patients from 2005 to 2010 who underwent AVR ± coronary artery bypass grafting for severe AS with a preoperative assessment of pulmonary pressures by right-sided cardiac catheterization. PH was defined as a mean pulmonary artery pressure of ≥25 mm Hg, with severity based on the pulmonary artery systolic pressure-mild, 35 to 44 mm Hg; moderate, 45 to 59 mm Hg; and severe, ≥60 mm Hg. We found that PH was present in 536 patients (48%). Postoperative acute kidney injury, low-output heart failure, and in-hospital mortality increased with worsening severity of PH. In multivariate logistic regression, severe PH was independently associated with postoperative acute kidney injury (adjusted odds ratio 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002) and in-hospital mortality (adjusted odds ratio 6.9, 95% CI 2.5 to 19.1, p <0.001). There was a significant association between PH and decreased 5-year survival (adjusted log-rank p value = 0.006), with severe PH being associated with the poorest survival (adjusted hazard ratio 2.4, 95% CI 1.3 to 4.2, p = 0.003). In conclusion, severe PH in patients with severe AS is associated with increased rates of in-hospital adverse events and decreased 5-year survival after AVR.

Current management of calcific aortic stenosis

Calcific aortic stenosis is a progressive disease with no effective medical therapy that ultimately requires aortic valve replacement (AVR) for severe valve obstruction. Echocardiography is the primary diagnostic approach to define valve anatomy, measure aortic stenosis severity, and evaluate the left ventricular response to chronic pressure overload. In asymptomatic patients, markers of disease progression include the degree of leaflet calcification, hemodynamic severity of stenosis, adverse left ventricular remodeling, reduced left ventricular longitudinal strain, myocardial fibrosis, and pulmonary hypertension. The onset of symptoms portends a predictably high mortality rate unless AVR is performed. In symptomatic patients, AVR improves symptoms, improves survival, and, in patients with left ventricular dysfunction, improves systolic function. Poor outcomes after AVR are associated with low-flow low-gradient aortic stenosis, severe ventricular fibrosis, oxygen-dependent lung disease, frailty, advanced renal dysfunction, and a high comorbidity score. However, in most patients with severe symptoms, AVR is lifesaving. Bioprosthetic valves are recommended for patients aged >65 years. Transcatheter AVR is now available for patients with severe comorbidities, is recommended in patients who are deemed inoperable, and is a reasonable alternative to surgical AVR in high-risk patients.

Eponyms in cardiopulmonary reflexes

Heart rate, blood pressure, and vascular tone, as well as ventilator drive, respiratory rate, and breathing pattern, are, at least in part, under the control of specific reflexes. These reflexes are mediated by a complex network of baroreceptors and chemoreceptors in the arterial system of the carotids, aorta, and left heart, including receptors in the left atrium, the ventricle, and the coronary arteries; irritants in the upper airways and stretch receptors in the lower airways; juxtacapillary-located nonmyelinated fibers in the alveoli and in the bronchial arterial system; and muscle spindles that evoke changes in the membrane potential upon alteration of sarcolemmal tension. Some of these reflexes, usually named after the first individual to describe them, have spread as eponyms into propaedeutic education and clinical work. Because these euphonic eponyms are enigmatic to most clinicians today, this article is intended to provide a short overview of these reflexes, including the historical context of their describers. As evidenced by their clinical implications, the eponyms discussed are revealed to be more than curiosities taught during undergraduate medical education.

Evolving strategies for the use of spironolactone in cardiovascular disease

The evolution of strategies for the use of spironolactone and its analogue, eplerenone, has, over the years, encompassed favourable modification of the natural history of symptomatic heart failure in subjects with subnormal left ventricular ejection fraction (LVEF), and mitigation of the risk of new-onset atrial fibrillation in mildly symptomatic systolic heart failure. Given the fact that these benefits might be attributable, at least in part, to mitigation of severity of diastolic dysfunction when the latter co-exists with subnormal LVEF, what needs to be explored is the possibility of similar benefits from the use of these agents in patients such as those with hypertension, and aortic valve stenosis, in whom left ventricular dysfunction is of the predominantly diastolic subtype.

Management of pulmonary hypertension in left heart disease

Pulmonary hypertension (PH) due to left heart disease is classified as group II according to the Dana Point classification, which includes left ventricular systolic and/or diastolic left heart failure, and left-sided valvular disease. PH due to left heart disease is the most common cause and when present, especially with right ventricular dysfunction, is associated with a worse prognosis. Left heart disease with secondary PH is associated with increased left atrial pressure, which causes a passive increase in pulmonary pressure. Passive PH could be superimposed by an active protective, and in some patients by an ‘out of proportion’, elevated precapillary pulmonary vasoconstriction and vascular remodelling which leads to greater or lesser further increase of the pulmonary artery pressure. In this review, epidemiological and pathophysiologic mechanisms for the development of group II PH are summarized. The conflicting data about the haemodynamic and possible parameters to diagnose passive versus reactive and ‘out of proportion’ PH are presented. The different therapeutic concepts, along with novel treatment strategies, are reviewed in detail and critically discussed regarding their effectiveness and safety.