Key result
Precapillary PH with PVR ≥3 Wood units linked to ~4.4-fold higher post-AVR mortality.
Why the study?
The clinical impact of the 2018 pulmonary hypertension definition compared with the 2015 definition had not been evaluated in patients with aortic stenosis undergoing aortic valve replacement.
Does the 2018 pulmonary hypertension definition, which includes a PVR ≥3 WU criterion, better predict long-term mortality compared to the 2015 definition in patients with severe aortic stenosis undergoing valve replacement?
Cohort (n=487)
No
Does the 2018 pulmonary hypertension definition, which includes a PVR ≥3 WU criterion, better predict long-term mortality compared to the 2015 definition in patients with severe aortic stenosis undergoing valve replacement?
Hazard Ratio: 4.4
Applying the 2018 PH definition using PVR ≥3 WU successfully identifies patients with severe aortic stenosis who have true pulmonary vascular disease and significantly increased long-term mortality after AVR.
PVR ≥3 WU may aid post-AVR risk stratification in severe AS; leaves open whether the 2018 precapillary PH definition improves prediction.
BACKGROUND: The new 2018 pulmonary hypertension (PH) definition includes a lower mean pulmonary artery pressure (mPAP) cut-off (>20 mmHg rather than ≥25 mmHg) and the compulsory requirement of a pulmonary vascular resistance (PVR) ≥3 Wood units (WU) to define precapillary PH. We assessed the clinical impact of the 2018 compared to the 2015 PH definition in aortic stenosis (AS) patients undergoing aortic valve replacement (AVR). METHODS: Severe AS patients (n = 487) undergoing pre-AVR right heart catheterization were classified according to the 2015 and 2018 definitions. Post-AVR mortality (median follow-up 44 months) was assessed. RESULTS: Based on the 2015 definition, 66 (13%) patients exhibited combined pre and postcapillary PH (CpcPH), 116 (24%) isolated post-capillary PH (IpcPH), 28 (6%) precapillary PH, and 277 (57%) no PH at all. Overall, 52 (11%) patients were reclassified: 23 no PH into IpcPH; 8 no PH into precapillary PH; 20 precapillary PH into no PH; 1 CpcPH into IpcPH. By the 2015 definition, only CpcPH patients displayed increased mortality, whereas by the 2018 definition, precapillary PH patients also experienced higher mortality than those without PH. Among the PH definition components, PVR ≥3 WU was the strongest predictor of death (hazard ratio > 4). CONCLUSIONS: In severe AS, a higher number of IpcPH patients are diagnosed by the 2018 definition, even though they have the same prognosis as those without PH. Patients with true precapillary PH are more accurately identified by the 2018 definition that includes a pulmonary vascular disease criterion, that is, PVR ≥3 WU, a strong mortality predictor.
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Maeder et al. (2021) conducted a cohort in Severe aortic stenosis (n=487). 2018 pulmonary hypertension definition criteria (specifically PVR ≥3 Wood units) vs. 2015 pulmonary hypertension definition criteria (PVR <3 Wood units) was evaluated on All-cause mortality post-aortic valve replacement (HR 4.4). In patients with severe aortic stenosis undergoing valve replacement, a pulmonary vascular resistance ≥3 Wood units (required for the 2018 precapillary PH definition) was the strongest predictor of death (HR 4.4).
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