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The Association of Body Mass Index on Outcomes in Patients undergoing Transcatheter Aortic Valve Implantation

https://doi.org/10.1007/s00392-025-02737-x

Jakob Johannes Reichl (Basel)1, A. Poljo (Basel)2, T. Stolte (Basel)1, R. Schmitt (Bad Krozingen)3, J. Boeddinghaus (Basel)1, M. Wagener (Basel)1, G. Leibundgut (Basel)1, C. A. Kaiser (Basel)1, D. Westermann (Freiburg im Breisgau)4, T. Hartikainen (Bad Krozingen)3, F. Mahfoud (Basel)1, P. Ruile (Bad Krozingen)3, P. Breitbart (Bad Krozingen)3, T. Nestelberger (Basel)1

1Universitätsspital Basel Abt. für Kardiologie Basel, Schweiz; 2Klinik für Viszeralchirurgie Clarunis - Universitäres Bauchzentrum Basel, Schweiz; 3Universitäts-Herzzentrum Freiburg / Bad Krozingen Klinik für Kardiologie und Angiologie Bad Krozingen, Deutschland; 4Universitäts-Herzzentrum Freiburg - Bad Krozingen Innere Medizin III, Kardiologie und Angiologie Freiburg im Breisgau, Deutschland

 

Background: Obesity is an escalating public health concern and is associated with adverse outcomes in cardiovascular disease (CVD). Recent studies have reported a paradoxical association between obesity and improved outcomes after transcatheter aortic valve implantation (TAVI), with lower mortality observed in obese patients. This study aims to investigate the obesity paradox and the influence of body mass index (BMI) on procedural and long-term clinical outcomes in patients undergoing TAVI. 

Materials and Methods: Patients undergoing TAVI at two large, high volume multinational centers were included in a combined analysis. Using the recent World Health Organization (WHO) classifications, patients were categorized into four BMI groups: underweight (BMI <18.5 kg/m2), normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obese (BMI ≥30.0 kg/m2). The primary outcome was technical success and safety, including 30-day rates of all-cause-mortality, stroke, and overall bleeding. Secondary outcomes included all-cause mortality at one and five years.

Results: A total of 6,156 patients were included in this analysis: 114 (1.8%) underweight, 2393 (38.8%) normal weight, 2380 (38.6%) overweight, and 1269 (20.6%) obese. No significant differences were observed between BMI groups for 30-day all-cause mortality, stroke, overall bleeding, or technical success rates. However, underweight patients had significantly higher all-cause mortality compared to normal-weight patients at one year (23.7 vs. 13.2%, adjusted Hazard Ratio 1.89, 95% CI 0.35-0.78, p=0.001) and five years (53.2% vs. 44.0%, aHR 1.4, 95% CI 1.0-2.0, p=0.048). Obese patients had similar mortality rates to normal-weight patients at one year (11.4 vs. 13.2%, aHR 0.85, 95% CI 0.70-1.04, p=0.120) and five years (41.0 vs. 44.0%, aHR 1.09, 95% CI 0.91-0.95, p=0.200). 

Conclusions: While obesity was not associated with improved short- or long-term outcomes compared to normal-weight patients, underweight at baseline was an independent predictor of higher all-cause mortality after TAVI. These findings challenge the obesity paradox in the context of TAVI.

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