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The Limits of Comorbidity Indices in TAVI: How Aggregation Dilutes the Prognostic Power of Individual Biomarkers
Nazile Bilgin Doğan1, Özdemir Kuzucu1
1Department of Cardiology, Turkish Ministry of Health Izmir Bayraklı City Hospital, Izmir 35540, Turkey.
Objective:
Heart-team decisions in transcatheter aortic valve implantation (TAVI) lean on EuroSCORE II, yet the comorbidity burden that often drives the final choice is rarely scored. We tested a specific two-part hypothesis: whether formally quantifying comorbidity burden (via the Charlson Comorbidity Index [CCI] and a modified CCI [mCCI]) recovers prognostic value beyond EuroSCORE II for Valve Academic Research Consortium-3 (VARC-3) outcomes, and whether aggregating comorbidities preserves or dilutes the prognostic signal of individually informative predictors.
Methods:
In 234 consecutive patients (mean age 76.6 ± 6.1 years) undergoing TAVI for severe aortic stenosis, EuroSCORE II, CCI, and mCCI were computed before the procedure. The primary endpoint was the 30-day VARC-3 composite; secondary endpoints were individual VARC-3 outcomes and one-year mortality. We compared discrimination (AUC, DeLong test) and incremental value with bootstrapping, and analyzed survival by Kaplan-Meier/Cox regression.
Results:
All three scores discriminated the 30-day composite (63 patients, 26.9%) poorly (AUCs 0.50-0.54), collapsing to chance after correction; neither comorbidity index improved on EuroSCORE II (all p > 0.40). EuroSCORE II's only meaningful signal was stage 3 acute kidney injury (AKI; AUC 0.676), where it significantly exceeded mCCI (p = 0.048). Serum albumin and chronic kidney disease (HR 2.97 for one-year mortality) were informative individually but not within an aggregate score.
Conclusions:
In elderly TAVI, the actionable prognostic information resided in individual markers of organ reserve-serum albumin and chronic kidney disease-that count-based comorbidity aggregation dissipated rather than concentrated. EuroSCORE II retained a focused, mechanistically coherent association with stage 3 AKI, reflecting its renal components. These findings support a shift from disease-counting toward direct measurement of organ reserve and frailty in TAVI risk assessment, and the development of TAVI-specific tools that preserve dominant individual predictors rather than averaging them into a single score.
