Simplified cardiac damage staging improves prognostic stratification compared with the genereux classification in patients undergoing transcatheter aortic valve implantation

Abstract Background Aortic stenosis is a disease where the prognosis is influenced by the degree of valve obstruction and by the extent of myocardial damage. In 2017 Généreux proposed a five-stage classification of extravalvular cardiac damage in severe AS, from isolated valvular disease to right-ventricular dysfunction. The One Hospital Clinical Service – SH TAVI Project, a multicenter registry including more than 10000 patients undergoing TAVI, provides an opportunity to examine the prognostic utility of cardiac-damage staging. Purpose This study aimed to: 1) Validate the Généreux classification in a large real-world TAVI cohort 2) Propose and test a simplified three-stage model that condenses the concept of cardiac damage. Methods All patients included underwent TAVI on or before May 31 2024, were screened and included those with baseline echocardiographic data sufficient for staging. Step 1: patients were categorized to the most advanced feature present, from Stage 4 backward to Stage 0. Stages were defined as follows: Stage 0: No cardiac damage Stage 1: Indexed LV mass 95 g/m² in women, 115 g/m² in men, E/e’14, or LVEF50% Stage 2: LA enlargement (34 mL/m²), AF or moderate/severe mitral regurgitation Stage 3: PAPs≥60 mmHg or moderate/severe tricuspid regurgitation Stage 4: Moderate/severe RV dysfunction (TAPSE16 mm) Step 2: Simplified three-stage model: Stage 0: No cardiac damage Stage 1: LV or LA/mitral damage (LVEF50%, AF or LA enlargement) Stage 2: PAPs≥60 mmHg and/or RV dysfunction (TAPSE16 mm). Endpoints were all-cause mortality, cardiovascular mortality, and heart failure related hospitalizations at 1 year. Composite outcomes (CV death or HF hospitalization) were analyzed as exploratory. Kaplan–Meier curves were compared by log-rank tests, and Cox models estimated adjusted hazard ratios. Pairwise comparisons were performed sequentially with Bonferroni correction. Results A total of 1902 patients were classified using the simplified model and 1289 patients using the Généreux classification. In the simplified model, outcomes worsened across stages: all-cause mortality increased from 7.2%, to 18.1% and 19.8% (P0.0001 overall; pairwise P0.0001 and P=0.048). CV mortality rose from 1.4% to 4.7% and 7.7% (P0.0001 overall; pairwise P=0.001 and P=0.008). Both endpoints remained independently associated with stage after adjustment for age, sex, comorbidities, and procedural factors. In contrast, the five-stage classification showed significant overall trends for all-cause and CV death (P0.05), but pairwise comparisons lost significance after correction. Conclusions In this large multicentric real-world TAVI cohort, a simplified model of cardiac damage demonstrated more consistent prognostic discrimination than the five-stage model. The simplified system captures the progression of left and right-sided damage using routinely available echocardiographic parameters, providing a pragmatic tool for everyday clinical practice.Simplified and Généreux stage modelsFor image description, please refer to the figure legend and surrounding text. Kaplan-Meier three and five stage modelsFor image description, please refer to the figure legend and surrounding text.