Key result
Both HFpEF (aHR 1.56; 95% CI 1.26-1.92; P<0.001) and HFrEF (aHR 1.60; 95% CI 1.21-2.13; P=0.001) phenotypes increased death or HF rehospitalization vs non-HFpEF after SAVR/TAVR.
Why the study?
In aortic stenosis, LVEF alone may not capture myocardial impairment, and the prevalence and prognostic impact of an HFpEF-like phenotype defined by LVEF and the HFA-PEFF score after SAVR or TAVR remained unclear.
Does the presence of an HFpEF or HFrEF phenotype based on LVEF and HFA-PEFF score increase the risk of all-cause death or heart failure rehospitalization compared to a non-HFpEF phenotype in patients with severe pure aortic stenosis undergoing SAVR or TAVR?
Cohort (n=1,739)
Yes
Does the presence of an HFpEF or HFrEF phenotype based on LVEF and HFA-PEFF score increase the risk of all-cause death or heart failure rehospitalization compared to a non-HFpEF phenotype in patients with severe pure aortic stenosis undergoing SAVR or TAVR?
In patients with severe pure aortic stenosis undergoing SAVR or TAVR, an HFpEF phenotype (defined by LVEF >=50% and HFA-PEFF score >=5) is present in over half of the cohort and confers an elevated risk of death or heart failure rehospitalization comparable to that of HFrEF.
HFpEF/HFrEF phenotypes identify higher post-AVR risk in severe AS; supports HFA-PEFF stratification but leaves open therapeutic implications.
Background In aortic stenosis (AS), left ventricular ejection fraction (LVEF) alone may not capture myocardial impairment, as some patients show heart failure with preserved ejection fraction (HFpEF)-like physiology. However, the prevalence and prognostic impact of this phenotype after aortic valve replacement remain unclear. Purpose This study aimed to classify patients undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) into three phenotypes by integrating LVEF with the HFA-PEFF score and to examine the prognostic implications of these phenotypes. Methods This multicentre registry included 2,811 consecutive patients who underwent SAVR or TAVR for severe AS from January 2016 through December 2021 at eight centres in Japan. After excluding 780 patients with ≥ moderate aortic regurgitation, ≥ moderate mitral regurgitation, ≥ moderate tricuspid regurgitation, or ≥ moderate mitral stenosis, and 292 patients with unavailable HFA-PEFF scores, 1739 patients (SAVR, n = 542; TAVR, n = 1197) with severe pure AS were included. Heart failure phenotypes were defined as follows: (1) non-HFpEF (LVEF ≥50% and HFA-PEFF score <5); (2) HFpEF (LVEF ≥50% and HFA-PEFF score ≥5); and (3) HFrEF (LVEF <50%). The primary endpoint was a composite of all-cause death or heart failure rehospitalization. Results The median age was 82 years (interquartile range [IQR], 77–86), and 1,057 patients (60.8%) were female. The median follow-up duration was 3.9 years (IQR, 2.2–5.3). 610 patients (35.1%) were categorized as the non-HFpEF group, 892 (51.3%) as the HFpEF group, and 237 (13.6%) as the HFrEF group. Compared with the non-HFpEF group, both the HFrEF group (adjusted hazard ratio [aHR], 1.60; 95% confidence interval [CI], 1.21–2.13; p = 0.001) and the HFpEF group (aHR, 1.56; 95% CI, 1.26–1.92; p < 0.001) were independently associated with a higher risk of the primary endpoint. These associations were also observed in analyses conducted separately in the SAVR and TAVR cohorts. Among 188 asymptomatic patients, 84 (44.7%) were categorized as the non-HFpEF group, 97 (51.6%) as the HFpEF group, and 7 (3.7%) as the HFrEF group. In minimally adjusted analyses (age, sex, and procedure [SAVR/TAVR]), the HFpEF group was associated with a higher risk of the primary endpoint than the non-HFpEF group (aHR, 2.23; 95% CI, 1.14–4.37; p = 0.015). Conclusions HFpEF phenotype was associated with poor prognosis after SAVR or TAVR, similar to the HFrEF phenotype. This phenotyping approach may help guide the timing of aortic valve intervention and support the selection of appropriate pharmacological therapy.
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Ohmori et al. (2026) conducted a cohort in Severe pure aortic stenosis undergoing SAVR or TAVR (n=1,739). HFpEF phenotype (LVEF ≥50% and HFA-PEFF score ≥5) and HFrEF phenotype (LVEF <50%) vs. Non-HFpEF phenotype (LVEF ≥50% and HFA-PEFF score <5) was evaluated on Composite of all-cause death or heart failure rehospitalization (aHR 1.56, 95% CI 1.26-1.92, p=<0.001). Both HFpEF (aHR 1.56; 95% CI 1.26-1.92; P<0.001) and HFrEF (aHR 1.60; 95% CI 1.21-2.13; P=0.001) phenotypes increased death or HF rehospitalization vs non-HFpEF after SAVR/TAVR.
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