Prognostic impact of heart failure phenotype based on left ventricular ejection fraction and HFA-PEFF score after surgical or transcatheter aortic valve replacement
T Ohmori, K Maeda, A Ohtani, Y Yanagino, K Hanada, T Taguchi, K Kumagai, K Inoue, S Yamada, Y Misumi, K Yamashita, A Kawamura, D Yoshioka, K Shimamura, S MiyagawaAbstract
Background
In aortic stenosis (AS), left ventricular ejection fraction (LVEF) alone may not capture myocardial impairment, as some patients show heart failure with preserved ejection fraction (HFpEF)-like physiology. However, the prevalence and prognostic impact of this phenotype after aortic valve replacement remain unclear.
Purpose
This study aimed to classify patients undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) into three phenotypes by integrating LVEF with the HFA-PEFF score and to examine the prognostic implications of these phenotypes.
Methods
This multicentre registry included 2,811 consecutive patients who underwent SAVR or TAVR for severe AS from January 2016 through December 2021 at eight centres in Japan. After excluding 780 patients with ≥ moderate aortic regurgitation, ≥ moderate mitral regurgitation, ≥ moderate tricuspid regurgitation, or ≥ moderate mitral stenosis, and 292 patients with unavailable HFA-PEFF scores, 1739 patients (SAVR, n = 542; TAVR, n = 1197) with severe pure AS were included. Heart failure phenotypes were defined as follows: (1) non-HFpEF (LVEF ≥50% and HFA-PEFF score <5); (2) HFpEF (LVEF ≥50% and HFA-PEFF score ≥5); and (3) HFrEF (LVEF <50%). The primary endpoint was a composite of all-cause death or heart failure rehospitalization.
Results
The median age was 82 years (interquartile range [IQR], 77–86), and 1,057 patients (60.8%) were female. The median follow-up duration was 3.9 years (IQR, 2.2–5.3). 610 patients (35.1%) were categorized as the non-HFpEF group, 892 (51.3%) as the HFpEF group, and 237 (13.6%) as the HFrEF group. Compared with the non-HFpEF group, both the HFrEF group (adjusted hazard ratio [aHR], 1.60; 95% confidence interval [CI], 1.21–2.13; p = 0.001) and the HFpEF group (aHR, 1.56; 95% CI, 1.26–1.92; p < 0.001) were independently associated with a higher risk of the primary endpoint. These associations were also observed in analyses conducted separately in the SAVR and TAVR cohorts. Among 188 asymptomatic patients, 84 (44.7%) were categorized as the non-HFpEF group, 97 (51.6%) as the HFpEF group, and 7 (3.7%) as the HFrEF group. In minimally adjusted analyses (age, sex, and procedure [SAVR/TAVR]), the HFpEF group was associated with a higher risk of the primary endpoint than the non-HFpEF group (aHR, 2.23; 95% CI, 1.14–4.37; p = 0.015).
Conclusions
HFpEF phenotype was associated with poor prognosis after SAVR or TAVR, similar to the HFrEF phenotype. This phenotyping approach may help guide the timing of aortic valve intervention and support the selection of appropriate pharmacological therapy.Overall cohortSAVR and TAVR cohort