Key result
An intermediate probability of pulmonary hypertension, defined by a tricuspid regurgitation velocity threshold of >2.55 m/s, was independently associated with an increased risk of all-cause mortality (HR 1.62) compared to a low probability group.
Why the study?
The guideline-recommended upper physiological tricuspid regurgitation velocity threshold of 2.8 m/s has been questioned, prompting evaluation of the prognostic significance of preoperative PH in aortic stenosis after valve replacement using 2.55 vs 2.8 m/s thresholds.
Does a lower TRV threshold of 2.55 m/s improve prognostic risk assessment for all-cause mortality compared to the standard 2.8 m/s threshold in patients with severe aortic stenosis undergoing aortic valve replacement?
Cohort (n=444)
No
Does a lower TRV threshold of 2.55 m/s improve prognostic risk assessment for all-cause mortality compared to the standard 2.8 m/s threshold in patients with severe aortic stenosis undergoing aortic valve replacement?
Hazard Ratio: 1.62 (95% CI 1.11–2.35)
p-value: p=0.01
A lower TRV threshold of 2.55 m/s, combined with right heart measurements, improves long-term mortality risk stratification in patients with severe aortic stenosis undergoing aortic valve replacement compared to the standard 2.8 m/s guideline threshold.
Background: The upper physiological threshold for tricuspid regurgitation velocity (TRV) of 2.8 m/s proposed by the Pulmonary Hypertension (PH) guidelines had been questioned. The aim of this study was to evaluate the prognostic significance of preoperative PH in patients with aortic stenosis, long-term after valve replacement, using two different TRV thresholds (2.55 and 2.8 m/s). Methods: Four hundred and forty four patients were included (mean age 73 ± 9 years; 55% male), with a median follow-up of 5.8 years (98% completed). Patients were divided into three PH probability groups according to guidelines (low, intermediate and high) for both thresholds (TRV ≤ 2.8 m/s and TRV ≤ 2.55 m/s), using right atrial area>18 cm 2 and right ventricle/left ventricle ratio>1 as additional echocardiographic variables. Results: In patients with measurable TRV ( n = 304), the low group mortality rate was 25% and 30%, respectively for 2.55 and 2.8 m/s TRV thresholds. The intermediate group with TRV > 2.55 m/s was an independent mortality risk factor (HR 2.04; 95% CI: 1.91 to 3.48, p = 0.01), in contrast to the intermediate group with TRV>2.8 m/s (HR 1.44; 95% CI: 0.89 to 2.32, p = 0.14). Both high probability groups were associated with an increased mortality risk, as compared to their respective low groups. When including all patients (with measurable and non-measurable TRV), both intermediate groups remained independently associated with an increased mortality risk: HR 1.62 (95% CI 1.11 to 2.35 p = 0.01) for the new cut-off point; and HR 1.43 (95% CI: 0.96 to 2.13, p = 0.07) for guidelines threshold. Conclusion: A TRV threshold of 2.55 m/s, together with right cavities measures, allowed a better risk assessment of patients with PH secondary to severe aortic stenosis, with or without tricuspid regurgitation.
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García-Ribas et al. (2021) conducted a cohort in severe aortic stenosis (n=444). Tricuspid regurgitation velocity > 2.55 m/s (intermediate pulmonary hypertension probability) vs. Tricuspid regurgitation velocity ≤ 2.55 m/s (low pulmonary hypertension probability) was evaluated on all-cause mortality (HR 1.62, 95% CI 1.11-2.35, p=0.01). An intermediate probability of pulmonary hypertension, defined by a tricuspid regurgitation velocity threshold of >2.55 m/s, was independently associated with an increased risk of all-cause mortality (HR 1.62) compared to a low probability group.
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