Multivalvular Involvement in Acute Heart Failure: Associations with One-Year Outcomes and the Right-Heart Phenotype

Background: Valvular heart disease frequently accompanies acute heart failure (AHF), yet most studies address single valve lesions, and the prognostic weight of concurrent multivalvular involvement is less well defined. We examined the prevalence of single- and multi-valve disease and its relationship with one-year mortality. Methods: We analyzed 530 consecutive patients enrolled in a prospective single-center AHF registry between February 2023 and June 2025 and followed for 12 months. Aortic, mitral and tricuspid disease was graded according to European Society of Cardiology/European Association of Cardiovascular Imaging (ESC/EACVI) criteria, a valve being considered involved when it carried at least moderate stenosis and/or regurgitation; multivalvular disease was defined as involvement of two or more valves. The primary endpoint was one-year all-cause mortality. Cox regression was adjusted for admission log N-terminal pro-B-type natriuretic peptide (NT-proBNP), frailty (Clinical Frailty Scale ≥ 5) and age. In-hospital acute kidney injury was examined descriptively but was not entered into the models, because it is ascertained after admission. Results: Overall, 71.3% of patients had at least one significantly diseased valve-mitral in 44.3%, tricuspid in 43.8% and aortic in 27.5%-and 34.9% had multivalvular involvement. One-year mortality rose stepwise with the number of valves involved: 19.7%, 24.9%, 36.3% and 54.0% for zero, one, two and three valves, respectively (log-rank p < 0.001), corresponding to a crude hazard ratio (HR) of 1.51 (95% confidence interval [CI] 1.28-1.78) per additional valve. Multivalvular versus single or no valve involvement carried a crude HR of 2.07 (1.51-2.84) and remained associated with mortality after adjustment (HR 1.48, 95% CI 1.06-2.07, p = 0.020), as did each additional valve (HR 1.22, 1.03-1.45, p = 0.023). Adjustment for clinically manifest right heart failure (HF) attenuated the association with mortality (HR 1.15, 95% CI 0.96-1.37), whereas the association with the triple composite remained significant (HR 1.19, 95% CI 1.03-1.36). Propensity-score adjustment excluding right HF retained the association with mortality (HR 1.43, 95% CI 1.02-2.00), whereas inclusion of right HF attenuated it (HR 1.33, 0.94-1.87). The association was not detectable in the 304 patients without clinically manifest right HF (HR 1.06, 0.80-1.41, p = 0.69). In a post-discharge sensitivity analysis, the adjusted associations were directionally similar but did not reach statistical significance. Conclusions: In hospitalized AHF, multivalvular involvement was common, followed a predominantly mitral-tricuspid pattern, and identified an older, frailer, more congested phenotype with substantial right-sided and chronic renal involvement. Valve burden showed a graded association with one-year mortality that persisted after adjustment for baseline prognostic characteristics, but was attenuated once right-sided involvement was taken into account, whether by direct adjustment or by propensity methods; the association was retained when right HF was omitted from the propensity model. Because right-sided variables lie downstream of significant tricuspid disease, this attenuation is what adjustment for an intermediate is expected to produce and does not establish absence of prognostic value. Cumulative valve burden is therefore best interpreted as a powerful phenotypic marker of a more advanced HF phenotype with prominent right-heart involvement, rather than as an independent causal determinant of mortality.