Comparison of different phenotypes of postcapillary pulmonary hypertension in patients undergoing transcatheter edge-to-edge mitral valve repair

Rico Osteresch (Bremen)1, K. Diehl (Bremen)1, U. Hanses (Bremen)1, A. Ben Ammar (Bremen)1, S. Alo (Bremen)1, J. Schmucker (Bremen)1, A. Fach (Bremen)1, C. Frerker (Lübeck)2, I. Eitel (Lübeck)2, H. Wienbergen (Bremen)1, R. Hambrecht (Bremen)1

1Bremer Institut für Herz- und Kreislaufforschung (BIHKF) Bremen, Deutschland; 2Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany; Center for Cardiovascular Research (DZHK), Partner site Hamburg - Kiel - Lübeck, Germany Lübeck, Deutschland


Background: Postcapillary pulmonary hypertension (pc-PH) is associated with increased mortality in patients with severe mitral regurgitation (MR). However, the influence of isolated pc-PH (IpcPH) and combined post- and precapillary pulmonary hypertension (CpcPH) on outcome is unclear.

Objective: To assess outcome of different types of pc-PH in patients undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) for severe MR.

Methods: Consecutive patients with severe MR and pc-PH (mean pulmonary artery pressure > 20 mmHg and pulmonary artery wedge pressure > 15 mmHg) who underwent M-TEER were included and followed prospectively. Patients were classified as having IpcPH (pulmonary vascular resistance (PVR) < 2 Wood units), CpcPH (PVR ≥ 2 Wood units) and CpcPH with severe precapillary component (PVR > 5 Wood units). Primary outcome was all-cause mortality during a median follow-up period of 16 ± 11 months.

Results: 508 patients were enrolled (median age 79 ± 7.4 years, 51.5 % female). 157 patients (30.9 %) had IpcPH, 246 patients (48.4 %) had CpcPH and 105 patients (20.7 %) had CpcPH with a severe precapillary component. At long-term follow-up, a significantly lower survival rate was observed in patients with CpcPH with a severe precapillary component (66.6 % vs. 75.0 % vs. 76.8 %; log-rank p = 0.026). In Cox regression analysis failed M-TEER procedures (hazard ratio (HR) 6.6; 95 % confidence interval (CI) 2.0 to 21.8; p = 0.002) and the invasively derived pulmonary artery pulsatility index (PAPi; HR 0.78; 95 % CI 0.64 to 0.93; p = 0.015) were the strongest predictors for all-cause mortality in this cohort of patients.

Conclusions: In patients undergoing M-TEER CpcPH with a severe precapillary component is common and is associated with worse outcome. Therefore, classification of pc-PH by right heart catheterization could improve the risk assessment of patients undergoing M-TEER.

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