Background: Classical low-flow low-gradient aortic stenosis (cLFLG AS) is associated with poor prognosis and adverse clinical outcomes despite transcatheter aortic valve implantation (TAVI). Identifying prognostic markers in this high-risk population may improve risk stratification and clinical management. This study aimed to investigate independent predictors of all-cause mortality in patients with cLFLG AS undergoing TAVI.

Methods: In this single-center retrospective study, 151 patients with cLFLG AS undergoing TAVI between January 2018 and December 2024 were included. Multivariable Cox proportional hazards regression analysis was performed to identify predictors of all-cause mortality. Two separate multivariable models incorporating tricuspid annular plane systolic excursion (TAPSE) and TAPSE/systolic pulmonary artery pressure (sPAP) ratio were constructed to evaluate the prognostic impact of right ventricular (RV) systolic function and RV–pulmonary vascular interaction. The prognostic performance of TAPSE was further assessed using receiver operating characteristic (ROC) and restricted cubic spline analyses.

Results: During a median follow-up of 26 (15-42) months, all-cause mortality occurred in 37 (25%) patients. In multivariable analysis, reduced TAPSE remained independently associated with all-cause mortality after adjustment for age and left ventricular ejection
fraction (LVEF) (HR: 0.11, 95% CI: 0.04-0.30, P < .001). A lower TAPSE/sPAP ratio was also independently associated with mortality (HR: 0.08, 95% CI: 0.01-0.85, P = .036). Advanced age and reduced LVEF were independently associated with mortality in both models. Time-dependent ROC analysis demonstrated consistent discriminative performance of TAPSE over time.

Conclusion: Reduced TAPSE, advanced age, and reduced LVEF were independent predictors of all-cause mortality in patients with cLFLG AS undergoing TAVI.