Effect of pulmonary hypertension on the prognosis of patients with severe aortic stenosis after transcatheter aortic valve replacement: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WEI Zhili ¹ , CHEN Yang ¹ , DONG Shuai ² , CHEN Hao ¹ , CHEN Yang ² , AN Zhijing ² , ZHANG Yalan ² ,  SONG Bing ²

1. The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, P. R. China;
2. Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, 730000, P. R. China;

Corresponding author：

SONG Bing, Email: songbingldyy@163.com

Keywords：

Aortic stenosis; pulmonary hypertension; transcatheter aortic valve replacement; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202307008

Video：

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Objective To systematically evaluate the impact of pulmonary hypertension (PH) on the prognosis of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Methods A computerized search was conducted in CNKI, Wanfang Data, VIP, CBM, PubMed, The Cochrane Library, EMbase, and Web of Science databases from inception to June 2023 for cohort studies on the prognostic impact of PH in severe AS patients undergoing TAVR. Two researchers independently screened the literature, extracted data, and assessed the quality of included studies. Stata 17.0 software was used for meta-analysis. Results A total of 16 cohort studies were included, all with Newcastle-Ottawa Scale scores≥7. Meta-analysis results showed that, compared with AS patients without PH, those with PH had significantly higher 1-year all-cause mortality after TAVR [OR=2.10, 95%CI (1.60, 2.75), P<0.01], 30-day all-cause mortality [OR=2.09, 95%CI (1.54, 2.83), P<0.01], and cardiovascular mortality [OR=1.49, 95%CI (1.18, 1.90), P<0.01]. The differences between the two groups in major bleeding events, stroke, myocardial infarction, pacemaker implantation, and postoperative renal failure were not statistically significant. For outcome indicators with significant heterogeneity, subgroup analyses were performed based on PH measurement methods, diagnostic criteria, and different types of PH. The results showed that most subgroup combined results were consistent with the overall findings and that heterogeneity was significantly reduced. Conclusion PH significantly increases the 30-day all-cause mortality, 1-year all-cause mortality, and cardiovascular mortality in patients with severe AS undergoing TAVR.

Citation： WEI Zhili, CHEN Yang, DONG Shuai, CHEN Hao, CHEN Yang, AN Zhijing, ZHANG Yalan, SONG Bing. Effect of pulmonary hypertension on the prognosis of patients with severe aortic stenosis after transcatheter aortic valve replacement: A systematic review and meta-analysis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(8): 1173-1180. doi: 10.7507/1007-4848.202307008 Copy

1.	Schewel J, Schmidt T, Kuck KH, et al. Impact of pulmonary hypertension hemodynamic status on long-term outcome after transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2019, 12(21): 2155-2168.
2.	Joseph J, Naqvi SY, Giri J, et al. Aortic stenosis: pathophysiology, diagnosis, and therapy. Am J Med, 2017, 130(3): 253-263.
3.	Maganti K, Rigolin VH, Sarano ME, et al. Valvular heart disease: diagnosis and management. Mayo Clin Proc, 2010, 85(5): 483-500.
4.	Lindman BR, Dweck MR, Lancellotti P, et al. Management of asymptomatic severe aortic stenosis: evolving concepts in timing of valve replacement. JACC Cardiovasc Imaging, 2020, 13(2 Pt 1): 481-493.
5.	Keymel S, Papadopoulos G, Minol JP, et al. Patients with severe aortic stenosis and coexisting pulmonary hypertension treated by transapical transcatheter aortic valve replacement: is there a need for increased attention? Catheter Cardiovasc Interv, 2020, 95(5): 1001-1008.
6.	Durmaz T, Ayhan H, Keleş T, et al. The effect of transcatheter aortic valve implantation on pulmonary hypertension. Echocardiography, 2015, 32(7): 1057-1063.
7.	Parikh R, Varghese B, Khatoon HN, et al. Increased mortality from complications of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement. Pulm Circ, 2017, 7(2): 391-398.
8.	Anderson JJ, Lau EM. Pulmonary hypertension definition, classification, and epidemiology in Asia. JACC Asia, 2022, 2(5): 538-546.
9.	Alushi B, Beckhoff F, Leistner D, et al. Pulmonary hypertension in patients with severe aortic stenosis: prognostic impact after transcatheter aortic valve replacement: pulmonary hypertension in patients undergoing TAVR. JACC Cardiovasc Imaging, 2019, 12(4): 591-601.
10.	Ben-Dor I, Goldstein SA, Pichard AD, et al. Clinical profile, prognostic implication, and response to treatment of pulmonary hypertension in patients with severe aortic stenosis. Am J Cardiol, 2011, 107(7): 1046-1051.
11.	Dahiya G, Kyvernitakis A, Elhamdani A, et al. Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis. J Heart Lung Transplant, 2023, 42(2): 275-282.
12.	Adamopoulos D, Pagoulatou S, Rovas G, et al. Prognostic implications of the novel pulmonary hypertension definition in patients with aortic stenosis after transcatheter valve replacement. J Clin Med, 2022, 11(15): 4279.
13.	Liu TX, Tanenbaum MT, Seo CH, et al. Left ventricular diastolic dysfunction and pulmonary hypertension: outcomes in SAVR. Thorac Cardiovasc Surg, 2023, 71(5): 398-406.
14.	Gutmann A, Kaier K, Reinecke H, et al. Impact of pulmonary hypertension on in-hospital outcome after surgical or transcatheter aortic valve replacement. EuroIntervention, 2017, 13(7): 804-810.
15.	Desai A, Desai DM, Jamil A, et al. Outcomes of preprocedural pulmonary hypertension on all-cause and cardiac mortality in patients undergoing transcatheter aortic valve implantation: a systematic review. Cureus, 2023, 15(1): e34300.
16.	Magne J, Mohty D, Piccardo A, et al. Impact of pulmonary hypertension on outcome in patients with severe aortic stenosis and preserved left ventricular ejection fraction. Clin Res Cardiol, 2017, 106(7): 542-550.
17.	Kokkinidis DG, Papanastasiou CA, Jonnalagadda AK, et al. The predictive value of baseline pulmonary hypertension in early and long term cardiac and all-cause mortality after transcatheter aortic valve implantation for patients with severe aortic valve stenosis: a systematic review and meta-analysis. Cardiovasc Revasc Med, 2018, 19(7 Pt B): 859-867.
18.	Al-Khadra Y, Darmoch F, Moussa Pacha H, et al. The outcomes of pulmonary hypertension patients with severe aortic stenosis who underwent surgical aortic valve replacement or transcatheter aortic valve implantation. Am J Cardiol, 2019, 124(4): 586-593.
19.	Luçon A, Oger E, Bedossa M, et al. Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: Study from the FRANCE 2 Registry. Circ Cardiovasc Interv, 2014, 7(2): 240-247.
20.	Miyamoto J, Ohno Y, Kamioka N, et al. Impact of periprocedural pulmonary hypertension on outcomes after transcatheter aortic valve replacement. J Am Coll Cardiol, 2022, 80(17): 1601-1613.
21.	O'Sullivan CJ, Wenaweser P, Ceylan O, et al. Effect of pulmonary hypertension hemodynamic presentation on clinical outcomes in patients with severe symptomatic aortic valve stenosis undergoing transcatheter aortic valve implantation: insights from the new proposed pulmonary hypertension classification. Circ Cardiovasc Interv, 2015, 8(7): e002358.
22.	Sultan I, Fukui M, Bianco V, et al. Impact of combined pre and postcapillary pulmonary hypertension on survival after transcatheter aortic valve implantation. Am J Cardiol, 2020, 131: 60-66.
23.	Barbash IM, Escarcega RO, Minha S, et al. Prevalence and impact of pulmonary hypertension on patients with aortic stenosis who underwent transcatheter aortic valve replacement. Am J Cardiol, 2015, 115(10): 1435-1442.
24.	Bishu K, Suri RM, Nkomo VT, et al. Prognostic impact of pulmonary artery systolic pressure in patients undergoing transcatheter aortic valve replacement for aortic stenosis. Am J Cardiol, 2014, 114(10): 1562-1567.
25.	Sinning JM, Hammerstingl C, Chin D, et al. Decrease of pulmonary hypertension impacts on prognosis after transcatheter aortic valve replacement. EuroIntervention, 2014, 9(9): 1042-1049.
26.	Medvedofsky D, Klempfner R, Fefer P, et al. The significance of pulmonary arterial hypertension pre- and post-transfemoral aortic valve implantation for severe aortic stenosis. J Cardiol, 2015, 65(4): 337-342.
27.	Grimard BH, Safford RE, Burns EL. Aortic stenosis: diagnosis and treatment. Am Fam Physician, 2016, 93(5): 371-378.
28.	Dumitrof LC, Nedelciuc I, Roca M, et al. The evolution of pulmonary hypertension and its prognostic implications post-TAVI-single center experience. Medicina (Kaunas), 2022, 58(9): 1182.
29.	Testa L, Latib A, De Marco F, et al. Persistence of severe pulmonary hypertension after transcatheter aortic valve replacement: incidence and prognostic impact. Circ Cardiovasc Interv, 2016, 9(6): e003563.
30.	Anghel R, Adam CA, Marcu DTM, et al. Cardiac rehabilitation in patients with peripheral artery disease: a literature review in COVID-19 era. J Clin Med, 2022, 11(2): 416.
31.	Anghel R, Adam CA, Mitu O, et al. Cardiac rehabilitation and mortality risk reduction in peripheral artery disease at 6-month outcome. Diagnostics (Basel), 2022, 12(6): 1500.
32.	Aalaei-Andabili SH, Bavry AA. Left ventricular diastolic dysfunction and transcatheter aortic valve replacement outcomes: a review. Cardiol Ther, 2019, 8(1): 21-28.
33.	Asami M, Lanz J, Stortecky S, et al. The impact of left ventricular diastolic dysfunction on clinical outcomes after transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2018, 11(6): 593-601.
34.	Ujihira K, Kohmoto T, Gimelli G, et al. The impact of increased pulmonary arterial pressure on outcomes after transcatheter aortic valve replacement. Catheter Cardiovasc Interv, 2020, 96(7): E723-E734.
35.	Weber L, Rickli H, Haager PK, et al. Hemodynamics prior to valve replacement for severe aortic stenosis and pulmonary hypertension during long-term follow-up. J Clin Med, 2021, 10(17): 3878.
36.	Zoltowska DM, Agrawal Y, Patel N, et al. Association between pulmonary hypertension and transcatheter aortic valve replacement: analysis of a nationwide inpatient sample database. Rev Recent Clin Trials, 2019, 14(1): 56-60.
37.	Lindman BR, Zajarias A, Maniar H, et al. Clinical and hemodynamic factors influence the risk of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement: insights from the PARTNER Ⅰ trial and registry. Circulation, 2014, 130(Suppl 2): Abstract 18892.
38.	Ahmad M, Del Cid Fratti J, Henien M, et al. Association between pulmonary hypertension and its effect on 30-day mortality, readmission, and cost after transcatheter aortic valve replacement: a multicenter study. Cureus, 2023, 15(6): e40976.
39.	Lindman BR, Zajarias A, Maniar HS, et al. Risk stratification in patients with pulmonary hypertension undergoing transcatheter aortic valve replacement. Heart, 2015, 101(20): 1656-1664.
40.	Schwartz LA, Rozenbaum Z, Ghantous E, et al. Impact of right ventricular dysfunction and tricuspid regurgitation on outcomes in patients undergoing transcatheter aortic valve replacement. J Am Soc Echocardiogr, 2017, 30(1): 36-46.
41.	Bandyopadhyay D, Modi V, Hajra A, et al. Effects of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement: an insight form the most recent national inpatlent sample. J Am Coll Cardiol, 2019, 73(9).
42.	Gössl M, Kane GC, Mauermann W, et al. Pulmonary hypertension in patients undergoing transcatheter aortic valve replacement: Discussion of the current evidence. Circ Cardiovasc Interv, 2015, 8(6): e002253.
43.	Masri A, Abdelkarim I, Sharbaugh MS, et al. Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement. Heart, 2018, 104(10): 821-827.

1. Schewel J, Schmidt T, Kuck KH, et al. Impact of pulmonary hypertension hemodynamic status on long-term outcome after transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2019, 12(21): 2155-2168.
2. Joseph J, Naqvi SY, Giri J, et al. Aortic stenosis: pathophysiology, diagnosis, and therapy. Am J Med, 2017, 130(3): 253-263.
3. Maganti K, Rigolin VH, Sarano ME, et al. Valvular heart disease: diagnosis and management. Mayo Clin Proc, 2010, 85(5): 483-500.
4. Lindman BR, Dweck MR, Lancellotti P, et al. Management of asymptomatic severe aortic stenosis: evolving concepts in timing of valve replacement. JACC Cardiovasc Imaging, 2020, 13(2 Pt 1): 481-493.
5. Keymel S, Papadopoulos G, Minol JP, et al. Patients with severe aortic stenosis and coexisting pulmonary hypertension treated by transapical transcatheter aortic valve replacement: is there a need for increased attention? Catheter Cardiovasc Interv, 2020, 95(5): 1001-1008.
6. Durmaz T, Ayhan H, Keleş T, et al. The effect of transcatheter aortic valve implantation on pulmonary hypertension. Echocardiography, 2015, 32(7): 1057-1063.
7. Parikh R, Varghese B, Khatoon HN, et al. Increased mortality from complications of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement. Pulm Circ, 2017, 7(2): 391-398.
8. Anderson JJ, Lau EM. Pulmonary hypertension definition, classification, and epidemiology in Asia. JACC Asia, 2022, 2(5): 538-546.
9. Alushi B, Beckhoff F, Leistner D, et al. Pulmonary hypertension in patients with severe aortic stenosis: prognostic impact after transcatheter aortic valve replacement: pulmonary hypertension in patients undergoing TAVR. JACC Cardiovasc Imaging, 2019, 12(4): 591-601.
10. Ben-Dor I, Goldstein SA, Pichard AD, et al. Clinical profile, prognostic implication, and response to treatment of pulmonary hypertension in patients with severe aortic stenosis. Am J Cardiol, 2011, 107(7): 1046-1051.
11. Dahiya G, Kyvernitakis A, Elhamdani A, et al. Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis. J Heart Lung Transplant, 2023, 42(2): 275-282.
12. Adamopoulos D, Pagoulatou S, Rovas G, et al. Prognostic implications of the novel pulmonary hypertension definition in patients with aortic stenosis after transcatheter valve replacement. J Clin Med, 2022, 11(15): 4279.
13. Liu TX, Tanenbaum MT, Seo CH, et al. Left ventricular diastolic dysfunction and pulmonary hypertension: outcomes in SAVR. Thorac Cardiovasc Surg, 2023, 71(5): 398-406.
14. Gutmann A, Kaier K, Reinecke H, et al. Impact of pulmonary hypertension on in-hospital outcome after surgical or transcatheter aortic valve replacement. EuroIntervention, 2017, 13(7): 804-810.
15. Desai A, Desai DM, Jamil A, et al. Outcomes of preprocedural pulmonary hypertension on all-cause and cardiac mortality in patients undergoing transcatheter aortic valve implantation: a systematic review. Cureus, 2023, 15(1): e34300.
16. Magne J, Mohty D, Piccardo A, et al. Impact of pulmonary hypertension on outcome in patients with severe aortic stenosis and preserved left ventricular ejection fraction. Clin Res Cardiol, 2017, 106(7): 542-550.
17. Kokkinidis DG, Papanastasiou CA, Jonnalagadda AK, et al. The predictive value of baseline pulmonary hypertension in early and long term cardiac and all-cause mortality after transcatheter aortic valve implantation for patients with severe aortic valve stenosis: a systematic review and meta-analysis. Cardiovasc Revasc Med, 2018, 19(7 Pt B): 859-867.
18. Al-Khadra Y, Darmoch F, Moussa Pacha H, et al. The outcomes of pulmonary hypertension patients with severe aortic stenosis who underwent surgical aortic valve replacement or transcatheter aortic valve implantation. Am J Cardiol, 2019, 124(4): 586-593.
19. Luçon A, Oger E, Bedossa M, et al. Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: Study from the FRANCE 2 Registry. Circ Cardiovasc Interv, 2014, 7(2): 240-247.
20. Miyamoto J, Ohno Y, Kamioka N, et al. Impact of periprocedural pulmonary hypertension on outcomes after transcatheter aortic valve replacement. J Am Coll Cardiol, 2022, 80(17): 1601-1613.
21. O'Sullivan CJ, Wenaweser P, Ceylan O, et al. Effect of pulmonary hypertension hemodynamic presentation on clinical outcomes in patients with severe symptomatic aortic valve stenosis undergoing transcatheter aortic valve implantation: insights from the new proposed pulmonary hypertension classification. Circ Cardiovasc Interv, 2015, 8(7): e002358.
22. Sultan I, Fukui M, Bianco V, et al. Impact of combined pre and postcapillary pulmonary hypertension on survival after transcatheter aortic valve implantation. Am J Cardiol, 2020, 131: 60-66.
23. Barbash IM, Escarcega RO, Minha S, et al. Prevalence and impact of pulmonary hypertension on patients with aortic stenosis who underwent transcatheter aortic valve replacement. Am J Cardiol, 2015, 115(10): 1435-1442.
24. Bishu K, Suri RM, Nkomo VT, et al. Prognostic impact of pulmonary artery systolic pressure in patients undergoing transcatheter aortic valve replacement for aortic stenosis. Am J Cardiol, 2014, 114(10): 1562-1567.
25. Sinning JM, Hammerstingl C, Chin D, et al. Decrease of pulmonary hypertension impacts on prognosis after transcatheter aortic valve replacement. EuroIntervention, 2014, 9(9): 1042-1049.
26. Medvedofsky D, Klempfner R, Fefer P, et al. The significance of pulmonary arterial hypertension pre- and post-transfemoral aortic valve implantation for severe aortic stenosis. J Cardiol, 2015, 65(4): 337-342.
27. Grimard BH, Safford RE, Burns EL. Aortic stenosis: diagnosis and treatment. Am Fam Physician, 2016, 93(5): 371-378.
28. Dumitrof LC, Nedelciuc I, Roca M, et al. The evolution of pulmonary hypertension and its prognostic implications post-TAVI-single center experience. Medicina (Kaunas), 2022, 58(9): 1182.
29. Testa L, Latib A, De Marco F, et al. Persistence of severe pulmonary hypertension after transcatheter aortic valve replacement: incidence and prognostic impact. Circ Cardiovasc Interv, 2016, 9(6): e003563.
30. Anghel R, Adam CA, Marcu DTM, et al. Cardiac rehabilitation in patients with peripheral artery disease: a literature review in COVID-19 era. J Clin Med, 2022, 11(2): 416.
31. Anghel R, Adam CA, Mitu O, et al. Cardiac rehabilitation and mortality risk reduction in peripheral artery disease at 6-month outcome. Diagnostics (Basel), 2022, 12(6): 1500.
32. Aalaei-Andabili SH, Bavry AA. Left ventricular diastolic dysfunction and transcatheter aortic valve replacement outcomes: a review. Cardiol Ther, 2019, 8(1): 21-28.
33. Asami M, Lanz J, Stortecky S, et al. The impact of left ventricular diastolic dysfunction on clinical outcomes after transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2018, 11(6): 593-601.
34. Ujihira K, Kohmoto T, Gimelli G, et al. The impact of increased pulmonary arterial pressure on outcomes after transcatheter aortic valve replacement. Catheter Cardiovasc Interv, 2020, 96(7): E723-E734.
35. Weber L, Rickli H, Haager PK, et al. Hemodynamics prior to valve replacement for severe aortic stenosis and pulmonary hypertension during long-term follow-up. J Clin Med, 2021, 10(17): 3878.
36. Zoltowska DM, Agrawal Y, Patel N, et al. Association between pulmonary hypertension and transcatheter aortic valve replacement: analysis of a nationwide inpatient sample database. Rev Recent Clin Trials, 2019, 14(1): 56-60.
37. Lindman BR, Zajarias A, Maniar H, et al. Clinical and hemodynamic factors influence the risk of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement: insights from the PARTNER Ⅰ trial and registry. Circulation, 2014, 130(Suppl 2): Abstract 18892.
38. Ahmad M, Del Cid Fratti J, Henien M, et al. Association between pulmonary hypertension and its effect on 30-day mortality, readmission, and cost after transcatheter aortic valve replacement: a multicenter study. Cureus, 2023, 15(6): e40976.
39. Lindman BR, Zajarias A, Maniar HS, et al. Risk stratification in patients with pulmonary hypertension undergoing transcatheter aortic valve replacement. Heart, 2015, 101(20): 1656-1664.
40. Schwartz LA, Rozenbaum Z, Ghantous E, et al. Impact of right ventricular dysfunction and tricuspid regurgitation on outcomes in patients undergoing transcatheter aortic valve replacement. J Am Soc Echocardiogr, 2017, 30(1): 36-46.
41. Bandyopadhyay D, Modi V, Hajra A, et al. Effects of pulmonary hypertension in patients undergoing transcatheter aortic valve replacement: an insight form the most recent national inpatlent sample. J Am Coll Cardiol, 2019, 73(9).
42. Gössl M, Kane GC, Mauermann W, et al. Pulmonary hypertension in patients undergoing transcatheter aortic valve replacement: Discussion of the current evidence. Circ Cardiovasc Interv, 2015, 8(6): e002253.
43. Masri A, Abdelkarim I, Sharbaugh MS, et al. Outcomes of persistent pulmonary hypertension following transcatheter aortic valve replacement. Heart, 2018, 104(10): 821-827.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Effect of pulmonary hypertension on the prognosis of patients with severe aortic stenosis after transcatheter aortic valve replacement: A systematic review and meta-analysis

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