Prevalence and Prognostic Implications of Pulmonary Hypertension in Patients With Severe Aortic Regurgitation

Background: Pulmonary hypertension (PH) has been shown to be associated with worse outcomes in patients with PH in small older studies. Objectives: We sought to evaluate the prevalence of PH in patients with severe aortic regurgitation (AR), its impact on mortality and symptoms, and regression after aortic valve replacement (AVR). Methods: A total of 821 consecutive patients with chronic ≥ moderate-severe AR on echocardiography from 2004 to 2019 were retrospectively analyzed. PH was defined as right ventricular systolic pressure (RVSP) >40 mmHg on transthoracic echocardiogram (mild-moderate PH: RVSP 40-59 mmHg, severe PH: RVSP > 60 mmHg). Clinical and echocardiographic data were extracted from the electronic medical record and echocardiographic reports. The diastolic function and filling pressures were manually assessed and checked, and the left ventricular (LV) volumes were traced by a level 3-trained echocardiographer. The primary objectives were prevalence of PH in patients with ≥ moderate-severe AR, its risk associations and impact on all-cause mortality as the primary outcome. Secondary outcomes were impact of PH on symptoms and change in RVSP at discharge post-AVR. Logistic and Cox proportional hazards regression were used to analyze these outcomes. Results: The mean age was 61.2 ± 17 years, and 162 (20%) were women. Mild-moderate PH was present in 91 (11%) patients and severe PH in 27 (3%). Larger LV size, elevated LV filling pressures, and ≥ moderate tricuspid regurgitation were associated with PH. During follow-up of 7.3 (6.3-7.9) years, 188 patients died. Compared to those without PH, risk of mortality was higher in mild-moderate PH [adjusted hazard ratio 1.59 (1.07, 2.36) (P = 0.021)] and severe PH [adjusted hazard ratio 2.90 (1.63, 5.15) (P < 0.001)]. Symptoms were also more prevalent in those with PH (P = 0.004). Of 396 patients who underwent AVR during the study period, 57 had PH. AVR similarly improved survival in patients without and with PH (p-interaction = 0.23), and there was regression in RVSP (≥8 mmHg drop) at discharge post-AVR in 35/57 (61%) patients with PH. Conclusions: PH was present in 14% of patients with AR and was associated with higher mortality and symptoms. The survival benefit of AVR was similar in patients without and with PH.