Transcatheter Aortic Valve Replacement in Aortic Stenosis Patients With New York Heart Association Functional Class III or IV

Background: Patients with symptomatic aortic stenosis are a vulnerable population with associated cardiac damage and a significant comorbidity burden. In this study we aimed to determine the rate, factors associated with, and prognostic value of poor functional status (New York Heart Association [NYHA] class III-IV) in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).

Methods: This multicenter study included 6363 transarterial TAVR patients, classified according to baseline functional status (NYHA class I or II vs III or IV).

Results: A total of 3800 (60%) patients presented with NYHA class III or IV before the TAVR procedure. Atrial fibrillation (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.11-1.58; P = 0.002), chronic kidney disease (CKD; OR, 1.73; 95% CI, 1.45-2.05; P < 0.001), chronic obstructive pulmonary disease (COPD; OR, 1.65; 95% CI, 1.32-2.05; P < 0.001), reduced left ventricular ejection fraction (OR, 2.28; 95% CI, 1.70-3.05; P < 0.001), and moderate and severe pulmonary hypertension were associated with a poor functional status. At 1-year follow-up, patients with NYHA class III or IV had higher rates of mortality (8.81 per 100 person-years [95% CI, 7.57-10.15] vs 13.12 per 100 person-years [95% CI, 11.80-14.58]; log rank, P < 0.001) and heart failure hospitalization (8.25 per 100 person-years [95% CI, 7.05-9.65] vs 12.5 per 100 person-years [95% CI, 11.24-14.00]; log rank, P = 0.005). Comorbidity factors (COPD, CKD) and signs of cardiac damage (atrial fibrillation, pulmonary hypertension) determined an increased risk of poorer clinical outcomes (P < 0.01 for all).

Conclusions: More than half of the patients undergoing TAVR in the contemporary era have presented with advanced functional class before the procedure, and this was associated with a greater comorbidity and cardiac damage burden. Patients with poorer baseline functional status exhibited worse clinical outcomes at 1-year follow-up. These findings highlight the need for further study on earlier interventions for patients with aortic stenosis.