Underweight or overweight patients with cardiovascular diseases are associated with different outcomes. However, the data on the relation between body mass index (BMI) and outcomes after transcatheter aortic valve implantation (TAVI) are not homogeneous. The aim of this study was to assess the role of low BMI on short and long-term mortality in real-world patients undergoing TAVI. We retrospectively included patients undergoing TAVI for severe aortic valve stenosis. Patients were classified into three BMI categories: underweight (< 20 kg/m2), normal weight (20–24.9 kg/m2) and overweight/obese (≥ 25 kg/m2). Our primary endpoint was long-term all-cause mortality. The secondary endpoint was 30-day all-cause mortality. A total of 794 patients were included [mean age 82.3 ± 5.3, 53% females]. After a median follow-up of 2.2 years, all-cause mortality was 18.1%. Patients in the lowest BMI group showed a higher mortality rate as compared to those with higher BMI values. At the multivariate Cox regression analysis, as compared to the normal BMI group, BMI < 20 kg/m2 was associated with long-term mortality independently of baseline risk factors and postprocedural adverse events (hazard ratio [HR] 2.29, 95% confidence interval [CI] 1.30–4.03] and HR 2.61, 95% CI 1.48–4.60, respectively). The highest BMI values were found to be protective for both short- and long-term mortality as compared to lower BMI values even after applying the same adjustments. In our cohort, BMI values under 20 kg/m2 were independent predictors of increased long-term mortality. Conversely, the highest BMI values were associated with lower mortality rates both at short- and long-term follow-up.
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Body mass index
Body surface area
Acute kidney injury
Transcatheter aortic valve implantation
Chronic kidney disease
Peripheral artery disease
Society of thoracic surgeons
Valvular academic research consortium
Chronic Kidney Disease Epidemiology Collaboration
Estimated glomerular filtration rate
Surgery aortic valve replacement
Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN (2014) Obesity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox. J Am Coll Cardiol 63(14):1345–1354
Nasi M, Patrizi G, Pizzi C, Landolfo M, Boriani G, Dei Cas A et al (2019) The role of physical activity in individuals with cardiovascular risk factors: an opinion paper from Italian Society of Cardiology-Emilia Romagna-Marche and SIC-Sport. J Cardiovasc Med 20(10):631–639
Horwich TB, Fonarow GC, Clark AL (2018) Obesity and the obesity paradox in heart failure. Prog Cardiovasc Dis 61(2):151–156
Benedetto U, Danese C, Codispoti M (2014) Obesity paradox in coronary artery bypass grafting: myth or reality? J Thorac Cardiovasc Surg 147(5):1517–1523
Oreopoulos A, Padwal R, Norris CM, Mullen JC, Pretorius V, Kalantar-Zadeh K (2008) Effect of obesity on short- and long-term mortality postcoronary revascularization: a meta-analysis. Obesity 16(2):442–450
Boriani G, Laroche C, Diemberger I, Fantecchi E, Meeder J, Kurpesa M et al (2018) Overweight and obesity in patients with atrial fibrillation: sex differences in 1-year outcomes in the EORP-AF General Pilot Registry. J Cardiovasc Electrophysiol 29(4):566–572
Samuels JD, Lui B, White RS (2021) Clearing up the obesity paradox in cardiac surgery. J Cardiothorac Vasc Anesth 35(3):959–960
Proietti M, Boriani G (2020) Obesity paradox in atrial fibrillation: implications for outcomes and relationship with oral anticoagulant drugs. Am J Cardiovasc Drugs 20(2):125–137
Elagizi A, Kachur S, Lavie CJ, Carbone S, Pandey A, Ortega FB et al (2018) An overview and update on obesity and the obesity paradox in cardiovascular diseases. Prog Cardiovasc Dis 61(2):142–150
Andò G, Basile G (2020) Sarcopenia: only one of the domains of frailty in patients undergoing transcatheter aortic valve implantation. J Cardiovasc Med 21(10):787–789
Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG et al (2010) Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 363(17):1597–1607
Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK et al (2016) Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 374(17):1609–1620
Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M et al (2019) Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med 380(18):1695–1705
Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ et al (2017) 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 38(36):2739–2791
Vahanian A, Alfieri OR, Al-Attar N, Antunes MJ, Bax J, Cormier B et al (2008) Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 34(1):1–8
Kappetein AP, Head SJ, Généreux P, Piazza N, van Mieghem NM, Blackstone EH et al (2012) Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg 42(5):S45-60
(2000) Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 894:1–253
Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al (2009) Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 22(1):1–23 (quiz 101-2)
Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S et al (2017) Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 30(4):372–392
Waduud MA, Giannoudi M, Drozd M, Sucharitkul PPJ, Slater TA, Blackman DJ et al (2020) Morphometric and traditional frailty assessment in transcatheter aortic valve implantation. J Cardiovasc Med 21(10):779–786
Thourani VH, Keeling WB, Kilgo PD, Puskas JD, Lattouf OM, Chen EP et al (2011) The impact of body mass index on morbidity and short- and long-term mortality in cardiac valvular surgery. J Thorac Cardiovasc Surg 142(5):1052–1061
Smith RL 2nd, Herbert MA, Dewey TM, Brinkman WT, Prince SL, Ryan WH et al (2012) Does body mass index affect outcomes for aortic valve replacement surgery for aortic stenosis? Ann Thorac Surg 93(3):742–746 (discussion 6–7)
Vaduganathan M, Lee R, Beckham AJ, Andrei AC, Lapin B, Stone NJ et al (2012) Relation of body mass index to late survival after valvular heart surgery. Am J Cardiol 110(11):1667–1678
Sannino A, Schiattarella GG, Toscano E, Gargiulo G, Giugliano G, Galderisi M et al (2017) Meta-analysis of effect of body mass index on outcomes after transcatheter aortic valve implantation. Am J Cardiol 119(2):308–316
Voigtländer L, Twerenbold R, Schäfer U, Conradi L, Balaban Ü, Bekeredjian R et al (2020) Prognostic impact of underweight (body mass index <20 kg/m(2)) in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation or surgical aortic valve replacement (from the German Aortic Valve Registry [GARY]). Am J Cardiol 129:79–86
Rabkin SW, Mathewson FA, Hsu PH (1977) Relation of body weight to development of ischemic heart disease in a cohort of young North American men after a 26 year observation period: the Manitoba Study. Am J Cardiol 39(3):452–458
Hubert HB, Feinleib M, McNamara PM, Castelli WP (1983) Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation 67(5):968–977
Manson JE, Colditz GA, Stampfer MJ, Willett WC, Rosner B, Monson RR et al (1990) A prospective study of obesity and risk of coronary heart disease in women. N Engl J Med 322(13):882–889
Koliaki C, Liatis S, Kokkinos A (2019) Obesity and cardiovascular disease: revisiting an old relationship. Metabolism 92:98–107
Bundhun PK, Li N, Chen MH (2015) Does an obesity paradox really exist after cardiovascular intervention?: A systematic review and meta-analysis of randomized controlled trials and observational studies. Medicine 94(44):e1910
Galyfos G, Geropapas GI, Kerasidis S, Sianou A, Sigala F, Filis K (2017) The effect of body mass index on major outcomes after vascular surgery. J Vasc Surg 65(4):1193–1207
Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopatin M (2007) An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J 153(1):74–81
Corcione N, Testa A, Ferraro P, Morello A, Cimmino M, Albanese M et al (2021) Baseline, procedural and outcome features of patients undergoing transcatheter aortic valve implantation according to different body mass index categories. Minerva Med 112(4):474–482
He S, Fang Z (2020) Incidence, predictors, and outcome of prosthesis–patient mismatch after transcatheter aortic valve replacement: a meta-analysis. Medicine 99(24):e20717
Mohty D, Dumesnil JG, Echahidi N, Mathieu P, Dagenais F, Voisine P et al (2009) Impact of prosthesis–patient mismatch on long-term survival after aortic valve replacement: influence of age, obesity, and left ventricular dysfunction. J Am Coll Cardiol 53(1):39–47
Panoulas VF, Chandrasekhar J, Busi G, Ruparelia N, Zhang Z, Mehilli J et al (2021) Prevalence, predictors, and outcomes of patient prosthesis mismatch in women undergoing TAVI for severe aortic stenosis: insights from the WIN-TAVI registry. Catheter Cardiovasc Interv 97(3):516–526
Leone PP, Regazzoli D, Pagnesi M, Sanz-Sanchez J, Chiarito M, Cannata F et al (2021) Predictors and clinical impact of prosthesis-patient mismatch after self-expandable TAVR in small annuli. JACC Cardiovasc Interv 14(11):1218–1228
Stolcova M, Meucci F, Moretti C, Chiriatti N, Marcelli C, Mattesini A et al (2021) Long-term echocardiographic findings after TAVR: 5-year follow-up in 400 consecutive patients. Intern Emerg Med. https://doi.org/10.1007/s11739-021-02689-w
Sgura FA, Arrotti S, Magnavacchi P, Monopoli D, Gabbieri D, Banchelli F et al (2020) Kidney dysfunction and short term all-cause mortality after transcatheter aortic valve implantation. Eur J Intern Med 81:32–37
Valenti AC, Vitolo M, Manicardi M, Arrotti S, Magnavacchi P, Gabbieri D et al (2021) Red blood cell distribution width in patients undergoing transcatheter aortic valve implantation: implications for outcomes. Int J Clin Pract 75(6):e14153
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GB received small speaker’s fees from Medtronic, Boston, Biotronik, Boehringer and Bayer outside of the submitted work. The other authors declare no conflict of interest.
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Sgura, F.A., Arrotti, S., Monopoli, D. et al. Impact of body mass index on the outcome of elderly patients treated with transcatheter aortic valve implantation. Intern Emerg Med (2021). https://doi.org/10.1007/s11739-021-02806-9
- Body mass index
- Obesity paradox
- Aortic valve stenosis
- Cardiovascular disease