ArticleESC heart failure2026
Phenotyping patients with a low-flow, low-gradient aortic stenosis and a preserved ejection fraction undergoing transcatheter aortic valve implantation.
Article in ESC heart failure, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundIn patients undergoing transcatheter aortic valve implantation (TAVI), low flow, low-gradient (LF-LG) often reflects reduced left ventricular ejection fraction (LVEF). However, characteristics and causes of worse outcomes in patients with paradoxical LF-LG and preserved ejection fraction (pEF) remains poorly understood.
objectivesTo phenotype LF-LG pEF patients using unsupervised echocardiographic clustering.
methodsWe included 827 patients undergoing TAVI (UMCG, the Netherlands). LF-LG pEF was defined as LVEF ≥50%, aortic valve area: ≤1.0 cm2, mean gradient <40 mmHg, and a stroke volume index <35 ml/m2. Principal component analysis on 323 AI-assessed echocardiographic parameters (US2.ai) was followed by K-means clustering, with internal (n = 405) and external (n = 173) (TUMunich, Germany) validation.
results216/628 patients with complete data (34%) had LF-LG pEF (mean age of 78.8 (± 7.19) years, 57.9% female). Two clusters were identified: cluster 1 (n = 77) showed distinct echocardiographic features related to HFpEF, including larger left and right atrial dimensions (volume, area, length, width, and circumference), and impaired left ventricular global longitudinal strain and a reduced left atrial reservoir strain (across multiple views). They were older and had higher rates of atrial fibrillation (AF) and heart failure (HF), and higher HFpEF scores (49.4% H2FPEF score ≥6 and 71.4% HFA-pEFF score ≥5), versus cluster 2 (n = 139). Cluster 1 had higher 1- and 5-year cardiovascular mortality and HF-hospitalization risk, comparable to that of classical LF-LG patients. Validation reproduced theseresults.
conclusionOne-third of TAVI patients with LF-LG aortic stenosis have an typical HFpEF/AF phenotype and a poor prognosis. They may benefit from guideline-directed HFpEF therapy, including SGLT-2 inhibitors and MRA.
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