Distinct Features of Predictive Profiles for Post-TAVR Functional Improvement and Mortality. Value of 6-minute Walk Test and Myocardial Work Analysis

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Abstract
Clinical improvement and survival benefit after transcatheter aortic valve replacement (TAVR) are difficult to predict. Despite the identification of multiple predictors of both endpoints, prognostic algorithms in patients undergoing TAVR are not well defined. Aim: To explore factors determining the lack of significant improvement in exercise capacity after TAVR, and investigate whether the predictive profile for poor functional response to TAVR (PFR) could also predict mortality. Methods and results: We enrolled 220 patients (78.0±6.4 yrs) with severe aortic stenosis who underwent TAVR. Pre- and post-procedural (3 months) data were collected, including clinical information, echocardiography with myocardial work assessment, and 6-minute walk test (6MWT). PFR was defined as an increase in 6MWT distance <40m. Only age and atrial fibrillation were independent predictors of both mortality and PFR. Mortality was associated with lower global work index (HR 0.99; p<0.001) and shorter 6MWT distance (HR 0.99; p=0.008). PFR was associated with higher global wasted work (OR 1.003; p=0.026) and less impaired 6MWT relative to predicted values (OR 0.19; p<0.001 for 6MWT <80% predicted). Unsupervised machine learning-based analysis (Partition Around Medoids algorithm) identified clusters associated with mortality but not with PFR. Conclusions: The predictive profiles for PFR and mortality after TAVR show only limited overlap, indicating that these two outcomes warrant distinct prognostic evaluations. The 6MWT may be useful in predicting the likelihood of both outcomes, with lower absolute values being associated with mortality, while higher percentage predicted values – with limited symptomatic benefit. Myocardial work analysis may further enhance prognostic assessment in this population. Abstract Figure:

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