JACC Advances · Jul 9, 2026

Clarifying the Obesity Paradox in Transcatheter Aortic Valve Replacement: Findings From the STS/ACC TVT Registry

By Kumar S, Naik H, Falluji N

BACKGROUND: Higher body mass index (BMI) has been associated with better outcomes after transcatheter aortic valve replacement (TAVR), but whether this "obesity paradox" varies by age is unclear. OBJECTIVES: The objective of the study was to determine whether age modifies the association between BMI and 1-year outcomes after TAVR. METHODS: The authors performed a retrospective analysis of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, including patients who underwent TAVR between January 2021 and February 2023. Patients were categorized by age (<65 or ≥65 years) and BMI (<25 or ≥25 kg/m²). The primary outcome was 1-year all-cause mortality. Secondary outcomes included major adverse cardiovascular and cerebrovascular events: stroke, cardiac mortality, myocardial infarction, and readmission. Inverse probability of treatment weighting regression models were used to assess outcomes. RESULTS: Among the 6,639 patients (mean age 76.7 ± 11.6 years; mean BMI 29.7 ± 9.9 kg/m²), 1-year all-cause mortality occurred in 427 (6.4%). Among patients <65 years, outcomes did not differ between BMI groups (P > 0.05). Among patients ≥65 years, BMI <25 kg/m² was associated with a higher risk of all-cause mortality (adjusted HR [aHR]: 1.29; 95% CI: 1.05 to 1.57; P = 0.013) and major adverse cardiovascular and cerebrovascular events (aHR: 1.20; 95% CI: 1.08-1.34; P = 0.001) vs those with BMI ≥25 kg/m². The association between higher BMI and lower mortality strengthened with advancing age and was significant in patients 75 to 84 years (aHR: 0.60; 95% CI: 0.44-0.82; P = 0.001) and ≥85 years (aHR: 0.36; 95% CI: 0.25-0.51; P < 0.001), but not in younger strata. CONCLUSIONS: Higher BMI was not uniformly protective. Among older adults, lower BMI was associated with a higher-risk phenotype and worse 1-year outcomes.

doi.org/10.1016/j.jacadv.2026.102985Open accessPubMed 42425041Populations