From symptoms to strategy: pre-procedural NYHA-class as a key to risk stratification and personalized TAVR-management

Transcatheter aortic valve replacement (TAVR) has become a widely used treatment option for severe aortic stenosis (AS), particularly in elderly and multimorbid patients. The New York Heart Association (NYHA) classification, which assesses the severity of heart failure (HF), is a key factor influencing TAVR outcomes. However, its impact on procedural success, complications, and outcomes remains underrepresented in recent studies.

In this multicenter study, data from 2,256 patients who underwent TAVR between 2017 and 2022 at two high-volume German Heart Centers were analyzed. Demographics, comorbidities, and peri-procedural parameters were evaluated to determine the influence of pre-procedural NYHA classification on complications, hospital stay, and outcomes. Multivariable logistic regression analyses were performed to assess the independent prognostic impact of pre-procedural NYHA class on 30-day and 1-year mortality.

NYHA class III/IV prior to the procedure was associated with higher peri-procedural complication rates, prolonged hospital stays, and increased mortality compared to class NYHA I/II. In particular, the rates for cardiopulmonary resuscitation (5.3% vs. 0.7%; p < 0.001), acute coronary intervention (1.9% vs. 0.0%; p = 0.006), vasopressor use >6 h (11.7% vs. 1.6%; p < 0.001), and renal replacement therapy (6.8% vs. 0.2%; p < 0.001) were higher. Procedure-related complications like vascular closure device failure (4.9% vs. 1.3%; p = 0.008), need for vascular surgery (9.0% vs. 6.3%; p = 0.002), and blood transfusion (9.4% vs. 4.7%; p = 0.017) were more common in NYHA IV. Median hospital stay was longer in NYHA IV (10.0 vs. 6.0 days; p < 0.001). The 30-day mortality rate was 8.3% (NYHA IV) vs. 1.4% (NYHA I/II), and 1-year mortality was 19.2% vs. 5.2% (p < 0.001). After multivariable adjustment for relevant clinical confounders, NYHA class IV remained independently associated with both 30-day and 1-year mortality.

Pre-procedural NYHA class provides important prognostic information in patients undergoing TAVR, with higher symptom burden associated with increased peri-procedural risk and mortality. These findings highlight the relevance of comprehensive pre-procedural evaluation and optimized timing of intervention. Incorporating functional status into pre-procedural assessment may support risk stratification and individualized patient management.