Long-term prognostic value of the H2FPEF score in patients undergoing transcatheter aortic valve implantation

Abstract

Aims: A considerable proportion of candidates for transcatheter aortic valve implantation (TAVI) have underlying heart failure (HF) with preserved ejection fraction (HFpEF), which can be challenging for diagnosis because significant valvular heart disease should be excluded before diagnosing HFpEF. This study investigated the long-term prognostic value of the pre-procedural H₂FPEF score in patients with preserved ejection fraction (EF) undergoing TAVI.

Methods and results: Patients who underwent TAVI between October 2013 and May 2017 were enrolled from the Optimized CathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation Japanese multicentre registry. After excluding 914 patients, 1674 patients with preserved EF ≥ 50% (median age: 85 years, 72% female) were selected for calculation of the H₂FPEF score and were dichotomized into two groups: the low H₂FPEF score [0-5 points; n = 1399 (83.6%)] group and the high H₂FPEF score [6-9 points; n = 275 (16.4%)] group. Patients with high H₂FPEF scores were associated with a higher prevalence of New York Heart Association Functional Class III/IV (59.3% vs. 43.7%, P < 0.001), diabetes (24.4% vs. 18.5%, P = 0.03), and paradoxical low-flow, low-gradient aortic stenosis (15.9% vs. 6.2%, P < 0.001). These patients showed worse prognoses than those with low H₂FPEF scores regarding the cumulative 2 year all-cause mortality (26.3% vs. 15.5%, log-rank P < 0.001), cardiovascular mortality (10.5% vs. 5.4%, log-rank P < 0.001), HF hospitalization (16.2% vs. 6.7%, log-rank P < 0.001), and the composite endpoint of cardiovascular mortality and HF hospitalization (23.8% vs. 10.8%, log-rank P < 0.001). After adjustment for several confounders, the high H₂FPEF scores were independently associated with increased risk for all-cause mortality [adjusted hazard ratio (HR), 1.48; 95% confidence interval (CI), 1.09-2.00; P = 0.011] and for the composite endpoint of cardiovascular mortality and HF hospitalization (adjusted HR, 1.95; 95% CI, 1.38-2.74; P < 0.001). Subgroup analysis confirmed the excess risk of high H₂FPEF scores relative to low H₂FPEF scores for the composite endpoint of cardiovascular mortality and HF hospitalization increased with a lower Society of Thoracic Surgeons (STS) score (STS score <8%: adjusted HR, 2.40; 95% CI, 1.50-3.85; P < 0.001; STS score ≥8%: adjusted HR, 1.34; 95% CI, 0.79-2.28; P = 0.28; P_interaction = 0.030).

Conclusions: The H₂FPEF score is useful for predicting long-term adverse outcomes after TAVI, including all-cause mortality, cardiovascular mortality, and HF hospitalization for patients with preserved EF. More aggressive interventions targeting HFpEF in addition to the TAVI procedure might be relevant in patients with high H₂FPEF scores, particularly in those with a lower surgical risk.

Keywords: Aortic stenosis; H2FPEF score; Heart failure; Long‐term outcomes; Preserved ejection fraction; Transcatheter aortic valve implantation.

Figure 1

Inclusion flow diagram of the study population. LVEF, left ventricular ejection fraction; TAVI, transcatheter aortic valve implantation.

Figure 2

H₂FPEF score distribution. Histograms show the population distribution of the H₂FPEF score.

Figure 3

Kaplan–Meier curves for the clinical outcome measures: high H₂FPEF score vs. low H₂FPEF score. Kaplan–Meier curves for (A) all‐cause mortality, (B) cardiovascular mortality, (C) heart failure hospitalization, and (D) the composite endpoint of cardiovascular mortality and heart failure hospitalization. The Kaplan–Meier curves were truncated at 2 years.

Figure 4

Forest plots for the adjusted hazard ratios (HRs) according to the H₂FPEF score groups. Forest plots for (A) all‐cause mortality and (B) the composite endpoint of cardiovascular mortality and heart failure hospitalization. Cumulative incidence was represented by the values at 2 years. The number of patients with event and the HRs were estimated through the 2 year follow‐up. To calculate HRs and interactions, we incorporated the risk‐adjusting variables listed in Tables 4A and 4B . CRF was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m². CI, confidence interval; STS, Society of Thoracic Surgeons.