Survival Benefit of Aortic Valve Replacement in Patients With Severe Aortic Regurgitation and Pulmonary Hypertension

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.