Shorter Time to TAVI Associated with Improved Mid-Term Outcomes in Acute Decompensated Aortic Stenosis

Acute decompensated aortic stenosis (ADAS)—defined as sudden symptom onset or deterioration, such as rest dyspnea or syncope, due to severe aortic stenosis—represents a high-risk clinical presentation associated with significant morbidity and mortality. Although transcatheter aortic valve implantation (TAVI) is increasingly favored for treating this cohort, delays in time to TAVI remain related to several factors. However, as McKenna and colleagues have shown, such delays are not benign.

In a retrospective, single-center cohort study of 276 patients with ADAS undergoing urgent TAVI during index hospitalization, McKenna and colleagues evaluated whether time from admission to TAVI influenced mid-term outcomes. Patients were stratified by the median time to TAVI (22 days), and the primary endpoint was a composite of all-cause mortality or heart failure hospitalization. The secondary endpoint was a composite of cardiovascular mortality or heart failure hospitalization. Median follow-up was 4.6 years.

At 1 year, the primary endpoint occurred in 58.0% of the overall cohort. Longer time to TAVI was associated with significantly worse outcomes. For every 5-day delay, the hazard ratio (HR) for the primary endpoint was 1.09 (95% CI, 1.04–1.16; P=0.001), and for the secondary endpoint, HR was 1.08 (95% CI, 1.01–1.16; P=0.023). Patients undergoing TAVI more than 22 days after admission had a 48% increased risk of death or HF hospitalization (HR 1.48; P=0.013).

The adverse impact of procedural delay was most pronounced in patients with advanced cardiac damage (AS stage >2), defined by right ventricular dysfunction, pulmonary hypertension, or ≥moderate tricuspid regurgitation. In this subgroup, every 5-day delay in TAVI was associated with a 17% increased risk of the primary outcome (HR 1.17; P<0.001), while no significant association was observed in patients with AS stage 2 or less. Similarly, patients presenting with syncope (vs dyspnea) experienced greater harm from treatment delay, suggesting that hemodynamic profiles may influence vulnerability to procedural timing.

The study population predominantly included patients with conventional high-grade aortic stenosis (interquartile ranges: aortic valve mean gradient, 34-54 mmHg; aortic valve area, 0.5-0.8 cm²; left ventricular ejection fraction, 37-58%). Patients with low-flow, low-gradient aortic stenosis tend to be sicker with worse outcomes both with and without TAVI. While these AS profiles tend to show improved outcomes with TAVI, they also tend to be underdiagnosed and undertreated. Timely intervention for these profiles may be even more critical, but this remains to be studied.

These findings underscore the prognostic importance of minimizing delays in TAVI for ADAS. While the observational nature of the study precludes causal inference, the data suggest that time to TAVI is a modifiable factor with direct implications for clinical outcomes. Future prospective studies and systems-level interventions aimed at expediting care may reduce mortality and the burden of heart failure in this growing patient population.