Invasive Hemodynamic Staging Classifi cation of Cardiac Damage in Patients With Aortic Stenosis Undergoing Valve Replacement

Background: An echocardiographic 5-stage classification of cardiac damage in aortic stenosis (AS) has been shown to provide prognostic information. We aimed to create an analogous classification based on invasive hemodynamics. Methods: We studied 421 patients (age 75 +/- 10 years, 59% men) with severe AS with complete invasive hemodynamics obtained before aortic valve replacement (AVR). Cardiac damage stages were defined as follows: stage 0, absence of any of the following criteria; stage 1, left-ventricular end-diastolic pressure >15 mm Hg; stage 2, mean pulmonary artery wedge pressure > 15 mm Hg; stage 3, pulmonary vascular resistance > 3 Wood units and/or systolic pulmonary artery pressure > 60 mm Hg; stage 4, mean right atrial pressure >15 mm Hg. Patients were hierarchically classified in a given stage (worst stage) if the criterion was met for that stage. Results: Sixty-seven (16%) patients were classified as stage 0, 113 (27%) as stage 1,151 (36%) as stage 2, 73 (17%) as stage 3, and 17 (4%) as stage 4. After a median (interquartile range) follow-up of 3.8 (2.7 to 5.2) years after AVR, mortality was highest in stage 4 (hazard ratio; 95% confidence interval: 6.17 (1.74-21.89) vs stage 0; P = 0.005 and stage 3 patients (hazard ratio; 95% confidence interval: 4.17 (1.39-12.49) vs stage 0; P = 0.01,whereas mortality did not differ between patients in stages 0 to 2. Conclusions: A staging system of cardiac damage based on invasive hemodynamic parameters in patients with severe AS undergoing AVR predicts mortality. Pulmonary vascular disease and high right-atrial pressure are the major drivers of mortality.