Prognostic impact of supranormal ejection fraction in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation

Abstract Introduction Left ventricular dysfunction is a well-established poor prognostic factor in patients with severe aortic stenosis (AS). A supra-normal left ventricular ejection fraction (snLVEF) has also emerged as a factor contributing to less favorable clinical outcomes after transcatheter aortic valve implantation (TAVI) (1,2). Despite this, there is no clear explanation for these outcomes. Purpose The aim of this study was to evaluate the prognosis of patients with snLVEF undergoing TAVI and understand their clinical and echocardiographic characteristics. Methods We conducted a retrospective cohort study of patients with severe AS undergoing TAVI at University of Naples Federico II. Patients were categorized into two cohorts based on their baseline LVEF before TAVI using a cutoff value of 65%: the snEF group (LVEF ≥65%) and the control group (LVEF between 35 and 65%). Patients lacking LVEF data or with LVEF 35% were excluded from analysis. All patients were followed for one year after TAVI. A primary outcome was a composite of all-cause death and cardiovascular rehospitalization. Continuous variables were compared using the Student’s t-test or Wilcoxon rank-sum test, and categorical variables using the Chi-square or Fisher’s exact test. A two-sided p 0.05 was considered significant. Survival was analyzed by the Kaplan–Meier method with log-rank testing, and Cox regression was used to assess associations between LVEF groups and outcomes. Analyses were performed using R (v. 4.3). Results From an initial population of 630 patients, 564 were included in the study, of whom 79 (14.0%) had a snEF and 485 (86.0%) had a normal or reduced ejection fraction. The main clinical and echocardiographic characteristics are shown in Figure 1. Patients with snEF were less frequently male and had a lower prevalence of coronary artery disease and prior percutaneous revascularization. Patients with LVEF ≥ 65% had a significantly lower EuroSCORE II, indicating a more favorable preoperative risk profile. The left ventricular mass index was increased in both groups but was significantly lower in patients with snEF. Relative wall thickness differed between groups, suggesting a concentric hypertrophic pattern in those with snEF. No significant differences in main clinical outcomes were observed between groups as illustrated in Figure 2, although vascular complications tended to be higher in the group of patients with LVEF between 35 and 65%. After multivariable adjustment, LVEF ≥ 65% was not associated with 1-year event risk and periprocedural complication. Conclusions LVEF remains a key prognostic parameter in the clinical decision-making process for patients with severe AS. In contrast with previous studies, the present study did not show significant differences in all-cause mortality or rehospitalization at one year in patients undergoing TAVI with either reduced/normal (35–65%) or supra-normal (≥65%) LVEF before the procedure.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.