From symptoms to strategy: pre-procedural NYHA-class as a key to risk stratification and personalized TAVR-management

Background Transcatheter aortic valve replacement (TAVR) is the standard treatment for aortic stenosis (AS), particularly in elderly or high-risk surgical patients. The New York Heart Association (NYHA) classification, which assesses the severity of heart failure (HF), is a key factor influencing TAVR outcomes. However, its impact on procedural success, complications, and outcomes remains underrepresented in recent studies. Methods In this multicenter study, data from 2,256 patients who underwent TAVR between 2017 and 2022 at two high-frequency German Heart Centers were analyzed. Demographics, comorbidities, and peri-procedural parameters were evaluated to determine the influence of pre-procedural NYHA classification on complications, hospital stay, and outcomes. Results Pre-procedural NYHA III/IV were associated with higher peri-procedural complication rates, prolonged hospital stays, and increased mortality compared to NYHA I/II. Specifically, rates were higher for cardiopulmonary resuscitation (5.3% vs. 0.7%; p<0.001), acute coronary intervention (1.9% vs. 0.0%; p=0.006), vasopressor use >6h (11.7% vs. 1.6%; p<0.001), and renal replacement therapy (6.8% vs. 0.2%; p<0.001). Procedure-related complications like vascular closure device failure (4.9% vs. 1.3%; p=0.008), need for vascular surgery (9.0% vs. 6.3%; p=0.002), and blood transfusion (9.4% vs. 4.7%; p=0.017) were more common in NYHA IV. Median hospital stay was longer in NYHA IV (10.0 vs. 6.0 days; p<0.001). The 30-day mortality rate was 8.3% (NYHA IV) vs. 1.4% (NYHA I/II), and 1-year mortality was 19.2% vs. 5.2% (p<0.001). Conclusions NYHA classification is a reliable predictor of TAVR outcomes, highlighting a distinct gradation in risk and recovery profiles associated with higher NYHA classes. The findings emphasize the critical role of comprehensive pre-procedural evaluation and timely intervention. These insights could shape future guidelines on patient selection and management in TAVR, ultimately enhancing survival rates and quality of life, particularly in high-risk patients.