更新的肺动脉高压定义和经导管主动脉瓣植入术后的结局。

Updated definition of pulmonary hypertension and outcome after transcatheter aortic valve implantation.

机构信息

Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy.

Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy

出版信息

Heart. 2023 Dec 15;110(1):27-34. doi: 10.1136/heartjnl-2023-322881.

DOI:10.1136/heartjnl-2023-322881

PMID:37414524

Abstract

OBJECTIVE

The European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown.

METHODS

579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH.

RESULTS

Out of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group.

CONCLUSIONS

New ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.

摘要

目的

欧洲心脏病学会指南最近为肺动脉高压（PH）和肺血管阻力（PVR；中位肺动脉压（mPAP）>20mmHg 而非 25mmHg，PVR>2 伍德单位而非 3 伍德单位）定义了新的截断值。经导管主动脉瓣植入术（TAVI）后这种更新分类的预后价值尚不清楚。

方法

共纳入 579 例经 TAVI 治疗并进行术前右心导管检查评估的连续患者。患者分为以下三组：（1）无 PH；（2）孤立性毛细血管前/混合性 PH（I-PreC/CoPH）；（3）孤立性毛细血管后 PH（I-PoC PH）。在随访期间评估全因死亡、心血管死亡和因心力衰竭（HF）住院的情况。我们还分析了残余术后 PH 的预后作用。

结果

579 例患者中，根据新标准有 299 例（52%）存在 PH，而根据旧标准有 185 例（32%）存在 PH。总体中位年龄为 82 岁，55.3%的患者为男性。与无 PH 的患者相比，PH 患者更常被诊断为慢性阻塞性肺疾病和心房颤动，且手术风险更高。在中位随访 2.9 年后，根据旧标准定义的 PH 与生存率（p<0.001）和 HF 住院率（p=0.002）较差相关，而与 PVR 值无关。使用新的截断值，仅在 PVR 升高的患者中 PH 与不良结局相关，而在 PH 患者与 PVR 值正常的患者和无 PH 的患者之间未发现差异。在 45%的病例中观察到术后 mPAP 正常化，但仅在 I-PoC PH 组中与长期生存率提高相关。