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CLINICAL STUDY: PULMONARY HYPERTENSION

Severe pulmonary hypertension in patients with severe aortic valve stenosis: clinical profile and prognostic implications

Joseph F. Malouf, MD, FACC^*,*, Maurice Enriquez-Sarano, MD, FACC^*, Patricia A. Pellikka, MD, FACC^*, Jae K. Oh, MD, FACC^*, Kent R. Bailey, PhD, Krishnaswamy Chandrasekaran, MD, FACC^*, Charles J. Mullany, MD, FACC and A. Jamil Tajik, MD, FACC^*

^* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
Section of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA

Manuscript received October 31, 2001; revised manuscript received April 17, 2002, accepted May 20, 2002.

^* Reprint requests and correspondence: Dr. Joseph F. Malouf, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.

OBJECTIVES: We analyzed the clinical characteristics and outcomes of 47 patients with severe pulmonary hypertension (PHT) and severe aortic valve stenosis (AS) from 1987 to 1999.

BACKGROUND: The prognostic implications of severe pulmonary hypertension in patients with severe AS are poorly understood.

METHODS: The mean age of patients was 78 years (range 47 to 91 years), and 37 patients (79%) were in New York Heart Association (NYHA) functional class III or IV. Aortic valve replacement (AVR) was performed in 37 patients (79%) and 10 patients (21%) were treated conservatively.

RESULTS: In the group that had AVR, there were six perioperative deaths (16%) and nine late deaths, resulting in a total mortality of 32%. In the conservatively treated group, there were eight deaths (80%) on follow-up. Severe PHT was an independent predictor of perioperative mortality. However, perioperative mortality was independent of the severity of left ventricular systolic dysfunction or concomitant coronary artery bypass grafting. Aortic valve replacement was associated with significant improvement in left ventricular ejection fraction, the severity of PHT and NYHA functional class. The difference between long-term survival of the operative survivors and the expected survival from life tables was not statistically significant.

CONCLUSIONS: The prognosis for patients with AS and severe PHT treated conservatively without AVR is dismal. Although AVR is associated with higher than usual mortality, the potential benefits outweigh the risk of surgery.

Abbreviations and Acronyms   AS   aortic valve stenosis   AVA   aortic valve area   AVR   aortic valve replacement   CABG   coronary artery bypass grafting   E/A   ratio of early to late mitral diastolic flow   LVEF   left ventricular ejection fraction   LVOT   left ventricular outflow tract   LVOTa   cross-sectional area of the left ventricular outflow tract   NYHA   New York Heart Association   PASP   pulmonary artery systolic pressure   PHT   pulmonary hypertension   TRV   tricuspid regurgitation velocity

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