Staging cardiac damage associated with aortic stenosis in patients undergoing transcatheter aortic valve implantation

BACKGROUND: A new staging classification of aortic stenosis (AS) characterizing the extent of cardiac damage was established and validated in patients undergoing transcatheter aortic valve implantation (TAVI). The present study was aimed to refine the staging system by integrating a quantitative evaluation of right ventricular (RV) dysfunction defined by current echocardiographic guideline recommendations. METHODS AND RESULTS: In a prospective TAVI registry, patients were categorized into the stages: no cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or RV damage (Stage 4) based on baseline echocardiography. Among 1133 eligible patients undergoing TAVI, 8 (3.4%) patients were categorized as Stage 0, 113 (10.0%) as Stage 1, 397 (35.0%) as Stage 2, 239 (21.1%) as Stage 3, and 346 (30.5%) as Stage 4. There was a stepwise increase in all-cause and cardiovascular mortality rates at 1 year according to increasing stages of secondary cardiac damage: 5.4% and 0% in Stage 0, 5.3% and 1.8% in Stage 1, 8.9% and 5.9% in Stage 2, 17.7% and 12.9% in Stage 3, and 25.8% and 19.9% in Stage 4, respectively. After multivariable adjustment, increasing stages of cardiac damage gradually correlated with all-cause and cardiovascular mortality. CONCLUSION: A significant number of patients with AS underwent TAVI only once cardiac damage has already occurred. Integrating a guideline-based definition of RV dysfunction increased the sensitivity of the staging system to identify patients at increased risk of death after TAVI.