Prognostic value of the H2 FPEF score in patients undergoing transcatheter aortic valve implantation

Abstract

Aims: The aim of this study was to assess the prognostic value of the H₂ FPEF score in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) and preserved left ventricular ejection fraction (EF).

Methods and results: In this multicentre study, a total of 832 patients from two German high-volume centres, who received TAVI for severe AS and preserved EF (≥50%), were identified for calculation of the H₂ FPEF score. Patients were dichotomized according to low (0-5 points; n = 570) and high (6-9 points; n = 262) H₂ FPEF scores. Kaplan-Meier and Cox regression analyses were applied to assess the prognostic impact of the H₂ FPEF score. We observed a decrease in stroke volume index (-2.04 mL/m² /point) and mean transvalvular gradients (-1.14 mmHg/point) with increasing H₂ FPEF score translating into a higher prevalence of paradoxical low-flow, low-gradient AS among patients with high H₂ FPEF score. One year after TAVI, the rates of all-cause (low vs. high H₂ FPEF score: 8.0% vs. 19.4%, P < 0.0001) and cardiovascular (CV) mortality (1.9% vs. 9.0%, P < 0.0001) as well as the rate of CV mortality or rehospitalization for congestive heart failure (6.4% vs. 23.2%, P < 0.0001) were higher in patients with high H₂ FPEF score compared with those with low H₂ FPEF score. After multivariable analysis, a high H₂ FPEF score remained independently predictive of all-cause mortality [hazard ratio 1.59 (1.28-2.35), P = 0.018] and CV mortality or rehospitalization for congestive heart failure [hazard ratio 2.92 (1.65-5.15), P < 0.001]. Among the H₂ FPEF score variables, atrial fibrillation, pulmonary hypertension, and elevated left ventricular filling pressure were the strongest outcome predictors.

Conclusions: The H₂ FPEF score serves as an independent predictor of adverse CV and heart failure outcome among TAVI patients with preserved EF. A high H₂ FPEF score is associated with the presence of paradoxical low-flow, low-gradient AS, the HFpEF in patients with AS. By identifying patients in advanced stages of HFpEF, the H₂ FPEF score might be useful as a risk prediction tool in patients with preserved EF scheduled for TAVI.

Keywords: Aortic stenosis; H2FPEF score; HFpEF; Paradoxical low gradient; TAVI.

Figure 1

H₂FPEF score distribution among the study population.

Figure 2

Unadjusted spline analyses for the association of the H₂FPEF score with (A) mean transvalvular pressure gradient (Pmean), (B) stroke volume index (SVI), (C) paradoxical low‐flow, low‐gradient aortic stenosis (PLF‐LG AS), and (D) normal‐flow, low‐gradient aortic stenosis (NF‐LG AS). Only patients with low‐gradient AS (Pmean < 40 mmHg) were included in PLF‐LG AS and NF‐LG AS. ESC, European Society of Cardiology.

Figure 3

Kaplan–Meier estimates according to low and high H₂FPEF scores for (A) all‐cause mortality, (B) cardiovascular (CV) mortality, (C) heart failure rehospitalization, and (D) the combined endpoint of CV mortality or heart failure rehospitalization.