Aortic valve replacement improves survival in severe aortic stenosis associated with severe pulmonary hypertension

Severe pulmonary arterial hypertension in patients with severe aortic stenosis (AS) carries a poor prognosis. There are limited data on the effect of aortic valve replacement (AVR) in these patients.

Our echocardiographic database between 1993 and 2003 was searched for patients with severe AS defined as a Doppler estimated aortic valve area of 0.8 cm2 or less and severe pulmonary hypertension defined as a pulmonary arterial systolic pressure 60 mm Hg or greater. Of the 740 patients with severe AS, 119 (16%) had severe pulmonary hypertension forming the study cohort. The AVR was performed in 36 (30%) of these patients. Survival of patients with and without AVR were compared and adjusted for comorbidities and group differences using the Cox regression model.

Characteristics of patients with severe pulmonary hypertension; age 75 +/- 13 years, 39% women, left ventricular ejection fraction 41 +/- 20%. Patients who underwent AVR had a significantly higher five-year survival of 65% compared with 20% for those treated medically (p < 0.0001). The relative mortality risk associated with AVR was 0.28 (95% confidence interval 0.22 to 0.36) and was independent of age, gender, ejection fraction, diabetes, coronary disease, serum creatinine level, and concomitant medical therapy such as beta blockers, angiotensin converting inhibitors, and statins. The benefit of AVR was further supported by sensitivity and propensity score analyses. Patients on conservative therapy had a 30-day mortality of 30% and a one-year mortality of 70%.

Aortic valve replacement in patients with severe pulmonary hypertension secondary to severe AS is associated with a huge survival benefit. Medical therapy alone carries a dismal prognosis and AVR should be considered urgently in severe AS patients with severe pulmonary hypertension.