Clarifying the Obesity Paradox in Transcatheter Aortic Valve Replacement

Figures

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  Figure 1. Adjusted 1-Year All-Cause Mortality According to Age Group and Body Mass Index Category Heat map showing IPTW-adjusted 1-year mortality estimates across 4 age categories (<65, 65-74, 75-84, and ≥85 years) stratified by BMI <25 kg/m2 and BMI ≥25 kg/m2. BMI = body mass index.

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  Figure 2. Age-Stratified HRs for 1-Year All-Cause Mortality for Body Mass Index ≥25 kg/m2 vs Body Mass Index <25 kg/m2 Forest plot showing the association between BMI category and IPTW-adjusted 1-year mortality across age strata and pooled older-age groups. Interaction by age group: likelihood-ratio chi-square = 7.85, df = 3, P = 0.039; P for interaction trend = 0.010. Abbreviation as in Figure 1.

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  Figure 3. Model-Derived Predicted 1-Year All-Cause Mortality Across Continuous Body Mass Index Values at Representative Ages Restricted cubic spline interaction plot showing predicted 1-year all-cause mortality across continuous BMI values at representative ages of 60, 70, 80, and 85 years. BMI and age were modeled using 4-knot restricted cubic splines, with knots placed at the 5th, 35th, 65th, and 95th percentiles of the observed analytic cohort distribution. Shaded bands represent 95% CIs. The vertical dashed line indicates BMI 25 kg/m2, the threshold used in the categorical primary analysis. Abbreviation as in Figure 1.

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  Central Illustration. Age-Dependent Nature of the Transcatheter Aortic Valve Replacement “Obesity Paradox” In TAVR patients from the STS/ACC TVT Registry, higher BMI was not uniformly protective; rather, BMI <25 kg/m2 identified a vulnerable older phenotype with increasing 1-year mortality after age 75 and higher MACCE/readmission risk, supporting frailty, nutrition/sarcopenia and recovery-focused assessment in older low-BMI candidates. BMI = body mass index; MACCE = major adverse cardiovascular and cerebrovascular events; NS = not significant; STS/ACC TVT = Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy; TAVR = transcatheter aortic valve replacement.