Clinical Impact of In-Hospital Hemoglobin Decline Without Overt Bleeding After Transcatheter Aortic Valve Replacement

The Valve Academic Research Consortium recently expanded its bleeding endpoint definition, recommending that any procedure-related blood loss should be classified as bleeding, even in the absence of a clinically evident source. However, the lack of specific reference thresholds for hemoglobin decline limits the ability to discriminate clinically relevant events and the prognostic utility of these criteria.

To evaluate the incidence, predictors, and prognostic implications of hemoglobin declines without overt bleeding in patients undergoing transcatheter aortic valve replacement (TAVR).

In this multicenter study, 9,759 TAVR patients were stratified according to the presence or absence of overt bleeding during hospitalization. Among patients without overt bleeding, hemoglobin decrease was classified according to baseline and nadir in-hospital values as minimal (>1 and <3 g/dL), minor (≥3 and <5 g/dL), or major (≥5 g/dL). The median follow-up duration was 28 months (Q1-Q3: 12-48 months).

Hemoglobin decreases occurred in 5,645 patients (57.8%), classified as minimal in 79.1%, minor in 18.3%, and major in 2.6%. Female sex, dual antiplatelet therapy, chronic kidney disease, and higher baseline hemoglobin determined an increased risk for significant decline (P < 0.01 for all), whereas radial secondary access acted as a protective factor (P = 0.001). A major hemoglobin decline significantly increased 30-day mortality (adjusted HR [aHR]: 3.05; 95% CI: 1.15-8.96). At 1 year, both minor (aHR: 1.42; 95% CI: 1.09-1.86) and major (aHR: 1.85; 95% CI: 1.13-3.03) declines were independently associated with up to a 2-fold increase in mortality risk.

An in-hospital hemoglobin decrease ≥3 g/dL after TAVR, even in the absence of overt bleeding, was very common and independently associated with worse outcomes. Stratifying periprocedural hemoglobin loss may support early risk identification, guide postprocedural management, and refine future endpoint definitions.