Baseline gradient, valve morphology and left ventricular recovery and survival after TAVR in reduced-ejection-fraction aortic stenosis: a retrospective cohort study

Background Recovery of left ventricular ejection fraction (LVEF) after transcatheter aortic valve replacement (TAVR) is common in patients with reduced-EF severe aortic stenosis, but the prognostic importance of the recovery trajectory relative to baseline haemodynamic and valve characteristics remains uncertain. We therefore examined these factors in a retrospective TAVR cohort. Methods We studied 257 consecutive patients with severe aortic stenosis and baseline LVEF <50% undergoing TAVR at a tertiary centre between 2012 and 2026, with at least one follow-up echocardiogram. We assessed LVEF recovery, baseline mean transvalvular gradient and bicuspid valve morphology and their associations with all-cause mortality. Results During a median follow-up of 37 months (51 deaths), 209 (81%) patients achieved LVEF ≥50%, with most recovery occurring within 6–12 months. A limited-recovery trajectory was not associated with subsequent mortality (12-month landmark HR 1.10, 95% CI 0.52 to 2.31). In contrast, a baseline mean gradient <40 mm Hg was associated with lower 5-year survival (66% vs 82%) and higher adjusted mortality (HR 2.44, 95% CI 1.29 to 4.65), with similar estimates after adjustment for surgical risk score and enrolment era. Bicuspid morphology was not associated with incomplete recovery or mortality, although clinically relevant associations could not be excluded. Conclusions In this retrospective cohort, baseline transvalvular gradient was more strongly associated with LV recovery and long-term survival than recovery trajectory or valve morphology. The findings suggest that baseline haemodynamic phenotype may provide prognostic information beyond subsequent LVEF recovery, but prospective multicentre confirmation with concurrent assessment of flow, valve area and myocardial reserve is required.