Risk stratification after transcatheter aortic valve implantation (TAVI) remains challenging, particularly in elderly patients with substantial frailty and comorbidity burden. The hemoglobin-to-red cell distribution width ratio (HRR) has recently emerged as an integrated biomarker reflecting anemia, systemic inflammation, and nutritional status. However, evidence regarding its prognostic value in patients undergoing TAVI remains limited.

This retrospective observational study included 584 consecutive patients who underwent TAVI for severe aortic stenosis between 2019 and 2023. Baseline HRR was calculated from preprocedural laboratory measurements. Patients were categorized into the low HRR group and the high HRR group according to a receiver operating characteristic–derived cut-off value (0.74). The primary endpoint was long-term all-cause mortality. Multivariable Cox regression analyses evaluated HRR as both a continuous and a categorical variable. Additional receiver operating characteristic, reclassification, and restricted cubic spline analyses were performed.

Patients in the low HRR group experienced significantly higher in-hospital, 30-day, one-year, and long-term all-cause mortality compared with those in the high HRR group (all P < 0.001). Kaplan-Meier survival analysis demonstrated significantly reduced long-term survival in the low HRR group (log-rank P < 0.001). HRR showed moderate discriminatory ability for one-year (AUC = 0.73) and long-term all-cause mortality (AUC = 0.70). HRR outperformed hemoglobin alone and improved risk discrimination and reclassification beyond the STS (Society of Thoracic Surgeons) score. In multivariable Cox regression analyses, HRR remained independently associated with long-term mortality when assessed as a continuous variable (HR = 0.09, 95% CI: 0.03–0.25, P < 0.001) and as a categorical variable (HR = 0.34, 95% CI: 0.24–0.49, P < 0.001), after adjustment for age, sex, STS score, and malignancy.

Preprocedural HRR is independently associated with long-term all-cause mortality after TAVI. HRR may provide complementary prognostic information when integrated into multiparametric risk assessment strategies for elderly patients undergoing TAVI.