Prognostic value of pulmonary hypertension in patients with low-flow low-gradient aortic stenosis

Previous studies have shown that patients with aortic stenosis (AS) and pulmonary hypertension (PHT) have a worse prognosis compared to those with normal pulmonary artery pressure (PAP). However, the prognostic value of PHT in patients with low-flow low-gradient aortic stenosis (LF-LG AS) has not been examined. The present study aimed to evaluate the prognostic value of PHT in patients with LF-LG AS treated conservatively or with aortic valve replacement (AVR). A total of 381 patients were prospectively enrolled in the TOPAS (Truly or Pseudo-severe Aortic Stenosis) study at our institute. Pulmonary artery systolic pressure (PASP) was estimated by Doppler-echocardiography. The cohort was divided into two groups based on the cutoff value of PAPS 40 mmHg, which was the best value to predict 5 years outcomes according to receiver operating characteristic (ROC) analysis. Uni- and multivariable survival analyses were conducted to evaluate the association between elevated PAPS and all-cause mortality. The mean age of the study population was 75 ± 9 years, 66% were men. The mean PASP was 41±13 mmHg. During a median follow-up of 1.52 (IQR: 0.6-4.3) years, 141 (37%) patients died. Using Kaplan-Meier survival curves analysis, patients with a PASP < 40 mmHg vs. > 40 mmHg had 5-year survival estimates of 88% and 75%, respectively (log-rank p< 0.001). Using multivariable Cox regression analysis adjusted for age, sex, body mass index, AVR as a time-dependent variable, renal function, STS score, and tricuspid annular plane systolic excursion, patients with a PAPS > 40 mmHg had a significant increased risk of all-cause mortality at 5 years when compared to those with a PAPS < 40 mmHg, (HR [95% CI] = 2.86 [1.01-8.04], p = 0.04). Pulmonary hypertension is an independent predictor of all-cause mortality in patients with LF-LG AS independently of the comorbidities and of right ventricular function. These findings suggest that the prognostic value of PHT may be useful to enhance risk stratification in this challenging population