Prognostic impact of integrated echocardiographic and electrocardiographic staging of atrial cardiomyopathy in severe aortic stenosis undergoing TAVI
R Mistrulli, E F Emiliano Fiori, T S Tatiana Storozhenko, S C Sara Corradetti, A K Anthony Kechichian, N K Nikolaos Stalikas, D A Davide Ausiello, P P Pasquale Paolisso, E Z Eleonora Zuppini, E B Emanuele Barbato, G V C Guy Van Camp, M P Martin Penicka, E W Eric Wyffels, L R Lisbeth Rossell, M V Marc VanderheydenAbstract
Background
Atrial cardiomyopathy (AtCM) is common in patients with severe aortic stenosis (AS), even when left ventricular ejection fraction (EF) is preserved. However, the interplay between structural (echocardiographic) and electrical (electrocardiographic) remodeling and their impact on clinical outcomes after Transcatheter Aortic Valve Implantation (TAVI) remain poorly defined. This study aims to evaluate the prognostic value of a combined echocardiographic and electrocardiographic staging of AtCM in patients without a history of atrial fibrillation (AF).
Methods
We analyzed 122 consecutive patients with severe AS and preserved EF who underwent TAVI between 2017 and 2024. Patients were stratified based on two AtCM risk domains:
The primary composite endpoint was all-cause mortality and heart failure (HF) hospitalization. The risk goup secondary endpoint was new-onset AF.
Results
Mean age was 82.3 ± 5.6 years. At baseline, 54.1% of patients had High Echo-Risk (Stage 3-4) and 19.7% had High ECG-Risk (Score 2). Multivariate analysis showed divergent predictive capabilities:Composite Endpoint (Death/HF): High Echo-Risk was a strong independent predictor (HR 4.17; 95% CI 1.46–11.95; p=0.0079), whereas High ECG-Risk was not significant (HR 1.46; p=0.604).New-Onset AF: High ECG-Risk was the sole predictor of AF (HR 3.00; 95% CI 1.02–8.76; p=0.045), while High Echo-Risk was not predictive (HR 1.02; p=0.960).Combined analysis identified distinct phenotypes: High Echo-Risk/Low ECG-Risk patients had significantly increased risk of HF/Death (HR 4.86, p=0.0078), while Low Echo-Risk/High ECG-Risk patients had the highest risk of AF (HR 8.99, p=0.0045). A double-risk profile (High Echo/High ECG) conferred the worst prognosis for both outcomes (figure 1, 2)
Conclusion
In patients with severe AS and preserved EF, atrial cardiomyopathy manifests through distinct pathophysiological domains. Echocardiographic staging (based on LAVI and strain) predominantly identifies the risk of "pump failure" (HF/mortality), while specific ECG scoring (focusing on advanced inter-atrial block) stratifies arrhythmic risk (AF). A comprehensive multimodal approach is essential for accurate pre-TAVI prognostic stratification and may help identify patients who require more intensive evaluation.Atrial Cardiomyopathy StagingUnivariate and Multivariate Cox Analysis