Background: In aortic stenosis (AS), depression is a relevant comorbidity. Its impact on quality-of-life or even outcome and prognosis is still a matter of debate. In addition, one could hypothesize that the occurrence of depression is linked to heart failure severity. This seems to be of interest since a novel staging classification of the extent of extra-valvular cardiac damage in AS has been introduced recently. The current study aimed to investigate how coexisting depression impacts patients' quality-of-live in association to the severity of cardiac damage and how treatment by TAVI affects depression.

Methods: 224 patients suffering from severe AS undergoing TAVI at the University Hospital Jena were classified according to the 2017 staging classification of extra valvular damage and further dichotomized into group A (stage 0 to 2) and group B (stage 3 and 4). Using the Hospital Anxiety and Depression Scale for Germany (HADS-D), patients were classified into depressive and non-depressive using the 8 points for depression as cut-off value. In addition, quality of life (QoL) and health status (EQ-5D-5L – 5 parameters, EQ VAS) as well as clinical frailty (CFS), brain natriuretic peptide (BNP) and 6 minute walk test (SMWT) were documented at baseline, 6 weeks, 6 months and 12 months after TAVI. 

Results: The patient cohort represents a typical TAVI collective (mean age: 78±8 years; 55% female; mean STS-Score: 4.39±3.04%). The distribution of stages according to the 2017 classification was as follows: 10 patients (4.5%) stage 0; 29 patients (12.9%) stage 1; 129 patients (57.6%) stage 2; 36 patients (16.1%) stage 3 and 20 patients (8.9%) stage 4. After dichotomization, 168 patients (75.0%) were assigned to group A and 56 patients (25.0%) to group B. The part of patients showing pathologic values in HADS-D for depression was 25.5% (57/224 patients) in the entire collective, 26.2% (44/168 patients) in group A and 23.2% (13/56 patients) in group B.  Most notably, the semi-quantitative level of depression assessed by HADS-D did not differ between group A (10.2±2.5) and B (10.8±2.4; p=n.s.). Irrespective of depression and with respect to QoL, CFS, BNP and SMWT, only BNP serum levels were significantly different between group A (558±704 pg/ml) versus B (1467±2624 pg/ml; p<0.001). When comparing depressive vs. non-depressive patients, there were significant differences with consistently worse values in depressive patients for all items of EQ-5D-5L including VAS and CFS in group A (p<0.05) and for the items EQ-5D-5L-mobility, -pain, -anxiety and VAS in group B (p<0.05). In contrast, BNP and SMWT were not different (p=n.s.) when comparing depressive vs. non-depressive patients within both groups. In patients’ revealing pathologic values for depression in HADS-D prior to TAVI, there were significant and stable improvements of depression over time. Interestingly, the significant improvement was observable already after 6 weeks in group A (p=0.001) and only after 6/12 months in group B (p=0.040).

Conclusion: The extent of cardiac damage did not relevantly influence patients' perception of disease severity in our study. In contrast, the presence of depression has enormous impact especially on parameters of EQ-5D-5L as a well-validated tool to asses QoL. Interestingly, the TAVI procedure resulted in a persisting improvement of mental health in depressive patients without any additional pharmacological or psychological intervention.