Original article
Adult cardiac
Survival Benefit of Aortic Valve Replacement in Patients With Severe Aortic Regurgitation and Pulmonary Hypertension

https://doi.org/10.1016/j.athoracsur.2009.05.025Get rights and content

Background

Severe pulmonary hypertension occurs in approximately 10% of patients with severe aortic regurgitation (AR). The potential survival benefit of aortic valve replacement (AVR) in these patients is not known, and was analyzed in a large cohort of patients.

Methods

Our echocardiographic data was screened for severe AR patients with severe pulmonary hypertension defined as pulmonary artery systolic pressure of 60 mm Hg or greater. Chart reviews were performed for clinical, pharmacologic, and surgical details, and survival data were analyzed as a function of AVR.

Results

Of the 506 patients with severe AR and measurable pulmonary artery pressures by echocardiography, 83 had severe pulmonary hypertension defined as a pulmonary artery systolic pressure of 60 mm Hg or greater. Severe pulmonary hypertension was associated with lower left ventricular ejection fraction (47% ± 22% versus 53% ± 19%, p = 0.006), larger left ventricular size (p = 0.03), and higher grades of mitral regurgitation (2.7 ± 1.2 versus 1.7 ± 1.1, p < 0.0001). Of the 83 patients with severe pulmonary hypertension, 32 underwent AVR, which was associated with better survival compared with patients who did not (1-year survival 90% versus 58% and 5-year survival 62% versus 22%, respectively; p = 0.004). After adjusting for comorbidities, AVR remained an independent predictor of better survival (hazard ratio 0.45, 95% confidence interval: 0.22 to 0.92, p = 0.03). This survival benefit of AVR was further supported by propensity score analysis.

Conclusions

Severe pulmonary hypertension occurs in approximately 16% of patients with severe AR and is associated with left ventricular enlargement with dysfunction and resultant mitral regurgitation. Aortic valve replacement is associated with an independent survival benefit in these patients.

Section snippets

Patient Population

This retrospective cohort study is from a large university medical center. This study was approved by our Institutional Review Board, which waived the need for patient consent because of the retrospective nature of the study. As described previously, our echocardiographic database between the years 1993 and 2007 was searched for patients with severe AR, defined by a jet height ratio of greater than 60% or prominent holodiastolic flow reversal in the distal aortic arch or abdominal aorta [3].

Baseline Patient Characteristics

The baseline features of the 83 patients with severe PHT are summarized in Table 1, along with the 423 patients without PHT. The two groups were comparable in terms of age, sex, LV wall thickness, and comorbidities such as hypertension, diabetes mellitus, and coronary artery disease. However, patients with PHT had greater LV end-diastolic dimensions (5.9 ± 1.2 cm versus 5.6 ± 1.0 cm, p = 0.03) and end-systolic dimensions (4.2 ± 1.3 cm versus 3.9 ± 1.2 cm, p = 0.02), lower LV ejection fraction

Comment

This observational study confirms that AVR can be performed with an acceptable operative mortality rate (3%) and that it may confer a survival benefit to severe AR patients with associated severe PHT. Our series is larger than all other reported series and has, additionally, comprehensive echocardiographic and pharmacologic data that have potential prognostic implications.

References (10)

There are more references available in the full text version of this article.

Cited by (0)

View full text