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. 2025 Nov;114(11):1565-1573.
doi: 10.1007/s00392-025-02698-1. Epub 2025 Jun 23.

Fighting time: the critical importance of pre-TAVR mortality risk prediction

Jasmin Shamekhi  1 , Marius Ebert  2 , Angelina Lorek  2 , Irina Eckardt  2 , Baravan Al-Kassou  2 , Mustafa Mousa Basha  2 , Marcel Weber  2 , Miriam Silaschi  3 , Farhad Bakhtiary  3 , Georg Nickenig  2 , Sebastian Zimmer  2
Affiliations

Fighting time: the critical importance of pre-TAVR mortality risk prediction

Jasmin Shamekhi et al. Clin Res Cardiol. 2025 Nov.

Abstract

Background: Symptomatic severe aortic valve stenosis (AS) is a life-threatening condition requiring prompt medical attention. While transcatheter aortic valve replacement (TAVR) is an effective treatment, current scheduling practices often do not account for individual patient risk profiles due to limited data on mortality rates during the waiting period and a lack of viable risk assessment. Consequently, non-prioritized wait times may be unacceptably long for high-risk patient populations.

Objective: This study aimed to evaluate the mortality rate of patients with symptomatic severe AS awaiting TAVR and identify pragmatic clinical risk predictors during this period.

Methods: Between January 2019 and December 2023, 2,454 patients with symptomatic severe AS, were scheduled for TAVR after an interdisciplinary Heart Team discussion at the Heart Center Bonn. Mortality during the waiting period was assessed, and the characteristics of survivors (patients who underwent TAVR) were compared to non-survivors (patients who died before the procedure).

Results: The median waiting time for TAVR was 41 days. A total of 105 (4.3%) patients died during the waiting period, with a median time to death of 29 days. By comparison, 30 day post-TAVR mortality, including the intervention, was 1.7%. Multivariate regression analysis identified independent predictors of pre-TAVR mortality including reduced left ventricular ejection fraction, decreased estimated glomerular filtration rate, mitral regurgitation, tricuspid regurgitation, and advanced heart failure symptoms. An IMPACT score, incorporating these parameters, strongly predicted outcome with a hazard ratio for mortality of 2.1 greatly outperforming both EuroSCORE II and STS-PROM. The IMPACT score of ≥ 5 identified high-risk patients with a pre-TAVR mortality rate of 12.6%.

Conclusion: The mortality rate for patients with symptomatic severe AS awaiting TAVR is unacceptably high. Utilizing the IMPACT score could enable precise risk stratification, identifying patients who require urgent or prioritized intervention to improve outcomes.

Keywords: Aortic valve stenosis; IMPACT score; Mortality rate; Risk stratification; TAVR; Transcatheter aortic valve replacement; Waiting time for TAVR.

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Conflict of interest statement

Declarations. Conflict of interest: Drs. G. Nickenig and S. Zimmer have received speaker honoraria from Abbott, Abiomed, AstraZeneca, Bayer, Boehringer Ingelheim, Daiichi, Novartis, Pfizer, Medtronic, Boston Scientific, and Edwards Lifesciences. Dr. M. Silaschi received research grants from Medtronic, LSI solutions and Artivion. The other authors report no conflicts of interest. Informed consent: Patients with severe aortic stenosis awaiting TAVR face high mortality, highlighting the need for timely intervention. The newly established IMPACT score predicts adverse outcomes, enabling risk stratification and prioritization of high-risk individuals. This tool aids in clinical decision-making, optimizing perioperative care and guiding resource allocation. Its implementation may reduce wait list mortality by improving triage and early intervention strategies. Further validation and research are needed to refine its predictive accuracy.

Figures

Fig. 1
Fig. 1
Mortality rate before and after scheduled TAVR. The median waiting time from indication to TAVR was 41 days. From the overall cohort, 4.3% patients died during the waiting time, whereas the 30-day mortality rate after TAVR was 1.7%
Fig. 2
Fig. 2
Composition of the Immediate Prognostic Assessment for Critical TAVR Score (IMPACT). The IMPACT score consists of five parameters including a reduced left ventricular ejection fraction, a decreased estimated glomerular filtration rate, mitral regurgitation, tricuspid regurgitation, and advanced heart failure symptoms
Fig. 3
Fig. 3
ROC analysis comparing different scoring systems for pre-TAVR mortality. The IMPACT score demonstrated strong predictive accuracy, with an area under the curve (AUC) of 0.81 for pre-TAVR mortality. It outperformed both the EuroSCORE II and STS-PROM in mortality prediction
Fig. 4
Fig. 4
Forest plot comparing the hazard ratio predicted by different scoring systems for pre-TAVR mortality. The IMPACT score predicted a hazard ratio for mortality of 2.122 (95% CI: 1.797–2.507)
Fig. 5
Fig. 5
A Observed pre-TAVR mortality of patients for each point value of the IMPACT score. In the low-risk group, the pre-TAVR mortality rate was similar to the baseline 30-day post-TAVR mortality rate of 1.7%. B Number of patients who survived or died, split by low and high IMPACT score. Patients with an IMPACT score ≥ 5 had significantly higher pre-TAVR mortality rates of 12.6%
Fig. 6
Fig. 6
Pre-TAVR cumulative survival in low and high IMPACT score cohort. Patients with an IMPACT score ≥ 5 had significantly higher pre-TAVR mortality rates compared to patients with an IMPACT score < 5
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