Loop Diuretic Therapy in Severe Aortic Stenosis: Marker of Organ Congestion, Unfavorable Hemodynamics, and Increased Post-Valve Replacement Mortality.

BACKGROUND: Loop diuretic therapy (LDT) is associated with increased mortality in heart failure. Severe aortic stenosis (AS) patients are at risk for heart failure and frequently on LDT. We assessed cardiac structure and function, organ congestion, filling pressures, and long-term outcomes of severe AS patients on LDT undergoing aortic valve replacement (AVR). METHODS: Consecutive patients with severe AS with [n = 157; median (interquartile range) daily torasemide dose: 10 (5-15) mg] or without (n = 346) LDT undergoing a detailed assessment of congestion (B-type natriuretic peptide, liver enzymes, systematic chest X-ray analysis) and cardiac catheterization before AVR with a post-AVR follow-up of several years were studied. RESULTS: Despite similar AS severity (indexed aortic valve area 0.41 ± 0.12 vs. 0.43 ± 0.12 cm2/m2) patients with LDT had more advanced biventricular remodeling and dysfunction, higher B-type natriuretic peptide [446 (245-991) vs. 150 (62-317) ng/L; p < 0.001], higher liver enzymes, higher chest x-ray congestion score [2 (1-4.5) vs. 1 (0-2) score points; p < 0.001], and higher mean right atrial pressure (8 ± 4 vs. 6 ± 3 mmHg) and mean pulmonary artery wedge pressure (21 ± 8 vs. 14 ± 6 mmHg; p < 0.001 for both) than those without. After a median post-AVR follow-up of 15 months functional capacity was worse, and estimated systolic pulmonary pressure was higher (37 ± 11 vs. 32 ± 8 mmHg; p < 0.001), and after a median follow-up of 44 months mortality was higher [hazard ratio 2.01 (95% confidence interval 1.17-3.77); p = 0.01] in LDT compared to non-LDT patients. CONCLUSIONS: LDT identifies AS patients with more advanced cardiac remodeling, more severe congestion, unfavorable hemodynamics, impaired post-AVR status, and increased post-AVR long-term mortality.