Aims: A history of cardiac decompensation (CD) in patients with aortic stenosis, due to increased afterload or myocardial malfunction, is one of the strongest predictors of outcomes even after correction of afterload by transcatheter aortic valve implantation (TAVI). We classified patients undergoing TAVI into those with an acute history of CD, prior history of CD, or no history of CD before TAVI and compared their clinical presentation, effects of the prescribed medication, and prognosis after successful transfemoral TAVI. 

Methods: Medical reports of patients with severe aortic stenosis discharged from hospital after TAVI were retrospectively screened for patients’ signs and symptoms of cardiac congestion, history of previous or acute CD, and discharge medication. Pre-interventional CT scans were analyzed for pleural effusion and psoas muscle area index (PMAi). Data were associated with all-cause mortality and cardiovascular events during a one-year follow-up.

Results: Compared with patients with a prior CD (n=573) or no CD (n=2270), patients with acute CD (n=103) presented in a significantly poorer clinical condition with more signs and symptoms of fluid overload (edema, pulmonary rales, pleural effusion); they also had a significantly higher burden of cardiovascular disease, higher risk scores, poorer left ventricular function, a higher prevalence of renal dysfunction and anemia, and a lower PMAi, suggesting greater frailty. Renin-angiotensin system inhibitors (RASI) at discharge were prescribed in 63.1%, 73.9%, and 79.2% (p<0.001) in patients with acute, prior, or no CD, respectively, while beta-blockers, mineralocorticoids, and loop diuretics were more often prescribed in patients with acute CD versus prior or no CD. One-year overall mortality rates were 32.0%, 15.7%, and 8.2%, and the combined event rates of cardiovascular death or CD in the first year after TAVI were 33.0%, 16.8%, and 7.8%, respectively (p<0.001). Survival curves remained significantly different, even after adjustment for all baseline, procedural, and therapeutic parameters that revealed univariate significance. Of all predictors of one-year mortality the following parameters revealed the strongest multivariable significance: prior atrial fibrillation (HR and 95% CI: 1.705 (1.330-2.186)), fluid overload (HR 1.639 (1.253-2.144), device success (HR 0.499 (0.369-0.675), RASI prescription (HR 0.619 (0.480-0.799), and acute CD (HR 1.783 (1.129-2.817). In all three CD groups, there was a strong association between prescription of RASI and improved one-year survival, with the most pronounced manifestation in patients with acute CD (survival rates of patients with RASI vs. no RASI prescription: acute CD 75.4 vs. 55.3%, p=0.027; prior CD 87.6 vs. 74.5% p<0.001; no CD 92.5 vs. 89.2%, p=0.013).

Conclusions: 

Among TAVI recipients, acute and even a prior CD were strong independent predictors of mortality. Accordingly, manifest fluid overload at the timepoint of TAVI is an indicator of patients at highest risk. RASI therapy seems to beneficially influence patients’ outcomes. Overall, these results indicate that the follow-up of patients with concomitant heart failure after successful TAVI is extremely important.