Right Ventricular Trajectories After Tavr and Interaction With Left–sided Filling Pressures

Background Right ventricular (RV) structural and/or functional impairment is a recognized prognostic marker in severe aortic stenosis. Whether early post–TAVI RV trajectories are prognostically informative, and whether their association with outcomes varies according to left–sided filling pressures, remains unclear. Methods We conducted a single–center observational study including 107 consecutive patients undergoing transcatheter aortic valve implantation (TAVI) (January 2023–June 2024). Transthoracic echocardiography was performed pre–procedure and reassessed pre–discharge, within 1 week. RV systolic dysfunction was defined as TAPSE ‹17 mm and/or S’ ‹9.5 cm/s and/or FAC ‹35%; RV dilation as RVD1 ›40 mm. RV abnormality (D) was defined as dysfunction and/or dilation, generating four trajectories: N to N (persistent normal), D to D (persistent abnormal), D to N (recovery), N to D (new abnormality). Pre–TAVI left–sided filling pressures were estimated by average E/e’ and LAVi. The primary endpoint was late 1–year all–cause mortality (days 31–365) using a landmark approach. Associations were tested with Cox proportional hazards models (unadjusted, age–adjusted, and multivariable including pre–TAVI E/e’ and LAVi), and stratified by E/e’ (‹14 vs ≥14). Results RV trajectories were: N to N n=68, D to D n=18, D to N n=11, N to D n=10. Late (31–365 days) deaths were 27 (25.2%). Compared with N to N, D to D was associated with higher late mortality in the unadjusted model (HR 3.78, p=0.002) and remained significant after adjustment for age, pre–TAVI E/e’, and LAVi (HR 3.91, p=0.015). D to N (HR 2.54, p=0.150) and N to D (HR 0.64, p=0.675) were not significant in the multivariable model. In stratified analyses, D to D predicted mortality in E/e’ ‹14 (HR 5.28, p=0.016) but not in E/e’ ≥14 (HR 3.06, p=0.236), where age was the only significant predictor (HR 1.27, p=0.021). Conclusions In a real–world TAVI cohort, persistent RV abnormality (D to D) identifies a high–risk phenotype for late mortality. The prognostic signal appears more evident when pre–TAVI filling pressure markers are not elevated, supporting an integrated left–right framework for post–TAVI risk stratification and warranting confirmation with formal interaction testing in larger cohorts.