Pulmonary Hypertension in Patients Undergoing Transcatheter Aortic Valve Replacement

1P ulmonary hypertension (PH) is a significant, often irrevers- ible, risk factor of early and late morbidity and mortality in patients undergoing transcatheter aortic valve replacement (TAVR).The widely used Society of Thoracic Surgeons (STSs) Predicted Risk of Mortality (STS-Predicted Risk of Mortality) risk score does not include PH and the commonly associated right ventricular (RV) dysfunction.Therefore, procedural risk of patients with severe PH undergoing TAVR is probably underestimated and consideration of its risk relies heavily on clinical, procedural, and anecdotal experience.In addition, literature on the management of patients with severe PH undergoing TAVR is scarce.Using 1 of our recent transapical TAVR patients as an illustrative example we, therefore, sought to discuss recent data on outcomes of patients with severe PH undergoing TAVR, emerging TAVR risk scores that incorporate severe PH and other TAVR-specific risk factors as well as a guideline on how to clinically manage patients with severe PH undergoing TAVR who often present as difficult hemodynamic challenges. Case PresentationAn 82-year-old (body mass index, 26.8 kg/m 2 ) insulin-dependent diabetic female (151 cm, 62 kg) with symptomatic severe calcific aortic stenosis (echocardiographically derived: mean transvalvular gradient 43 mm Hg, maximal velocity 4.3 m/s and a calculated valve area of 0.5 cm 2 ) and preserved left ventricular (LV) function with an ejection fraction of 60%.She has severe coronary artery disease, is status post coronary artery bypass graft surgery with patent grafts to left anterior descending and ramus intermedius; the circumflex artery is only moderately diseased and the right coronary artery is small, nondominant with mild, diffuse disease (<1.5 mm in size).The right heart hemodynamics are summarized in Figure 1 and Table 1 with mild-to-moderate right heart failure (increased RV end-diastolic pressure) and severe mixed PH with a low-normal cardiac output.Her pulmonary artery wedge pressure (PAWP) was high without a dominant v wave.Because her echocardiogram did not show significant mitral valve nor aortic valve regurgitation, the high filling pressures were felt secondary to the long standing severe aortic valve stenosis with LV hypertrophy and associated LV diastolic dysfunction.The echocardiogram showed furthermore a preserved RV function with mild RV enlargement.We did not assess her pulmonary vascular reactivity during the right heart catheterization.She had no history of pulmonary thromboembolism or pulmonary disease, her preoperative pulmonary function test was within normal limits.Her most recent laboratory data are summarized in Table 2.Because of her cardiovascular history, comorbidities, and high STS risk score (10.8%), our heart team decided to offer TAVR.Because of significant peripheral vascular disease (<6-mm-sized iliac arteries bilaterally), she underwent transapical TAVR with a 23-mm Edwards Sapien valve.