TAVR in an Underserved Minority Population with Very Severe Aortic Stenosis: The Bronx Sign study

Background: Transcatheter aortic valve replacement (TAVR) is the standard treatment for high-gradient aortic stenosis (HG-AS), yet underserved populations, such as those in the Bronx, NY, often present with delayed diagnoses and advanced disease. We propose the "Bronx sign," defined as a mean transaortic valve gradient (mmHg) exceeding the patient’s age (years), to identify patients at higher risk of adverse outcomes post-TAVR. Purpose: This study aimed to evaluate hemodynamic and clinical outcomes in severe HG-AS patients stratified by the presence of the Bronx sign. Methods: In this retrospective, single-center study, we analyzed 90 patients with severe HG-AS undergoing transfemoral TAVR at Montefiore Medical Center, Bronx, NY, between January 2018 and December 2024: 30 with and 60 without the Bronx sign. The primary endpoint was the incidence of mild or greater paravalvular leak (PVL) at 30 days. The secondary endpoint, a composite of death, myocardial infarction, stroke and heart failure hospitalization, was evaluated at 1 year. Results: Bronx sign patients were younger (69 vs. 79 years, p<0.001), lower risk (STS 2.4% vs. 5.0%, p<0.001), and had fewer comorbidities, but presented with more advanced AS, including higher mean gradients (76.6 mmHg vs. 48.1 mmHg, p<0.001) and smaller valve areas (0.61 cm² vs. 0.70 cm², p=0.054). The primary endpoint of 30-day mild or greater PVL occurred more frequently in Bronx sign patients (29.6% vs. 6.1%, p=0.014). Mild or greater PVL was already present at discharge (16.7% vs. 3.3%, p=0.04) and persisted at 1 year (42.9% vs. 7.7%, p=0.014). Multivariable analysis identified the Bronx sign as the only independent predictor of PVL at 30 days (OR 8.93, 95% CI: 1.50–53.17). Incidence of the secondary endpoint was comparable between groups (23.3% vs. 23.3%, p=1.00). Post-procedural mean transaortic gradients were higher in Bronx sign patients (12.9 mmHg vs. 10.5 mmHg, p=0.033), but equalized by 30 days and 1 year. Periprocedural and 30-day clinical outcomes showed no significant differences. Conclusions: Bronx sign patients had significantly higher mild or greater PVL rates post-TAVR, persisting through 1 year, despite similar peri-procedural and long-term clinical outcomes compared to controls. These findings underscore the need for proactive measures to ensure equitable healthcare access for minority communities, addressing diagnostic delays and optimizing outcomes in these populations.