Prognostic implications of pre- and post-procedural heart failure in patients undergoing aortic valve replacement

Heart failure is a frequent manifestation in patients with severe aortic stenosis (AS), yet its timing in relation to aortic valve replacement (AVR) and its prognostic implications remain underexplored. We aimed to assess the clinical characteristics and outcomes of patients who developed heart failure before or after isolated AVR and identify those at highest risk.

We conducted a retrospective observational study of 451 consecutive patients with isolated, symptomatic, severe AS who underwent surgical or transcatheter AVR at two centers between 2013 and 2017. Patients with other significant valvular lesions or coronary artery disease were excluded. Heart failure was defined as hospitalization for congestive symptoms. Median follow-up was 56 months. All-cause mortality and heart failure rehospitalization were recorded.

Heart failure occurred in 133 patients (29.5%) prior to AVR and in 60 patients (13.3%) during follow-up. Patients with heart failure-either before or after AVR-were older, predominantly female, and showed signs of more advanced extravalvular cardiac damage. Persistent heart failure (heart failure both before and after AVR) was observed in 30 patients and was associated with the worst prognosis: 76.7% all-cause mortality during follow-up vs 19.1% in patients who never experienced heart failure, P<0.001. Predictors of post-AVR heart failure included age, female sex, baseline atrial fibrillation, prior heart failure, and higher body mass index.

Heart failure, whether occurring before or after AVR, is common and linked to poor outcomes. Persistent heart failure identifies a particularly high-risk subgroup. Heart failure in severe AS reflects not only valvular obstruction but also widespread cardiac dysfunction and patient-specific vulnerability.