# Epicardial adipose tissue and muscle distribution affect outcomes in very old patients after transcatheter aortic valve replacement

## TL;DR

This study shows that body fat distribution and muscle levels are important for predicting long-term survival in elderly patients after heart valve replacement.

## Contribution

The study identifies epicardial and visceral fat, muscle area, and GDF-15 as independent predictors of mortality in very old TAVR patients.

## Key findings

- Higher epicardial and visceral fat areas are linked to increased long-term mortality.
- Reduced psoas muscle area is an independent predictor of mortality.
- Elevated GDF-15 levels strongly predict adverse outcomes in these patients.

## Abstract

To analyse the relevance of body composition and blood markers for long-term outcomes in very old patients after transcatheter aortic valve replacement (TAVR).

A total of 403 very old patients were characterized with regard to subcutaneous, visceral, and epicardial fat, psoas muscle area, plasma growth differentiation factor 15 (GDF-15), and leptin. Cohorts grouped by body mass index (BMI) were analysed for long-term outcomes. Patients underwent transapical and transfemoral TAVR (similar 30-day/1-year survival). Body mass index >35 kg/m2 showed increased 2- and 3-year mortality compared with BMI 25–34.9 kg/m2 but not compared with BMI <25 kg/m2. Fat areas correlated positively to BMI (epicardial: R2 = 0.05, P < 0.01; visceral: R2 = 0.20, P < 0.001; subcutaneous: R2 = 0.13, P < 0.001). Increased epicardial or visceral but not subcutaneous fat area resulted in higher long-term mortality. Patients with high BMI (1781.3 mm2 ± 75.8, P < 0.05) and lean patients (1729.4 ± 52.8, P < 0.01) showed lower psoas muscle area compared with those with mildly elevated BMI (2055.2 ± 91.7). Reduced psoas muscle area and increased visceral fat and epicardial fat areas were independent predictors of long-term mortality. The levels of serum GDF-15 were the highest in BMI >40 kg/m2 (2793.5 pg/mL ± 123.2) vs. BMI <25 kg/m2 (2017.6 pg/mL ±130.8), BMI 25–30 kg/m2 (1881.8 pg/mL ±127.4), or BMI 30–35 kg/m2 (2054.2 pg/mL ±124.1, all P < 0.05). Increased GDF-15 level predicted mortality (2587 pg/mL, area under the receiver operating characteristic curve 0.94). Serum leptin level increased with BMI without predictive value for long-term mortality.

Morbidly visceral and epicardial fat accumulation, reduction in muscle area, and GDF-15 increase are strong predictors of adverse outcomes in very old patients post-TAVR.

Graphical Abstract