Percutaneous treatment of aortic stenosis and mitral regurgitation in the same patient

Mixed-Valve Disease: Management of Patients with Aortic Stenosis and Mitral Regurgitation: Thresholds for Surgery Versus Percutaneous Therapies

Significant mitral regurgitation (MR), frequently seen in the presence of severe aortic stenosis (AS), results in an association that negatively affects prognosis and imposes particular challenges for both the assessment of the severity of valvular lesions and decisions regarding treatment allocation. This article reviews the available literature with regards to the assessment of MR and AS in the presence of both; surgical management and results in patients with concomitant AS and MR; the effect of MR on outcomes in patients undergoing transcatheter aortic valve replacement; the effect of transcatheter aortic valve replacement on MR severity; and percutaneous treatment for MR after transcatheter aortic valve implantation. The authors aim to provide assistance in the decision-making process to treat patients with either a higher-risk double-valve procedure or a simpler, but perhaps incomplete, single-valve option.

A systematic review of reported cases of combined transcatheter aortic and mitral valve interventions

OBJECTIVES

To summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI).

BACKGROUND

CTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve-in-valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve-in-valve/valve-in-ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high-surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described.

METHODS

We performed a systematic review of all the published articles from PUBMED and EMBASE.

RESULTS

A total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6-365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post-procedure was rare.

CONCLUSIONS

CTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future.

A Glimpse into the Future: In 2020, Which Patients will Undergo TAVI or SAVR?

Transcatheter aortic valve implantation (TAVI) has evolved into a safe and effective procedure to treat symptomatic patients with severe aortic stenosis (AS), with predictable and reproducible results. Rates of important complications such as vascular complications, strokes and paravalvular leaks are lower than ever, because of improved patient selection, systematic use of multidector computer tomography, increasing operator experience and device iteration. Accumulating data suggest that transfemoral TAVI with newer generation transcatheter heart valves and delivery systems is superior to conventional surgical aortic valve replacement among intermediate- and high-risk patients with severe symptomatic AS with regard to all-cause mortality and stroke. One can anticipate that by 2020, the majority of patients with severe symptomatic AS will undergo TAVI as first line therapy, regardless of surgical risk.

Transcatheter Aortic Valve Replacement 2016: A Modern-Day "Through the Looking-Glass" Adventure

Transcatheter aortic valve replacement (TAVR) has become a safe and effective therapy for patients with severe aortic stenosis (AS). In recent trials, the hemodynamic performance and clinical outcomes of the latest generation of TAVR devices demonstrated at least parity with surgical outcomes in patients of similar risk. Many initial obstacles with TAVR have largely been overcome, including frequent access site complications and concerns about strokes and paravalvular leaks. Using a multidisciplinary heart team approach, patient selection, procedural planning, and device implantation have been refined and optimized such that clinical outcomes are generally predictable and reproducible. Future research will focus on the durability of TAVR devices, further enhancements in clinical outcomes, and adjunctive therapies. On the basis of initial results from ongoing clinical trials, the indication for TAVR will likely expand to lower-risk patients. This review provides an overview of recent progress in this field, and highlights future opportunities and directions.

An up-to-date overview of the most recent transcatheter implantable aortic valve prostheses

Over the past decade transcatheter aortic valve implantation (TAVI) has evolved towards the routine therapy for high-risk patients with severe aortic valve stenosis. Technical refinements in TAVI are rapidly evolving with a simultaneous expansion of the number of available devices. This review will present an overview of the current status of development of TAVI-prostheses; describes the technical features and applicability of each device and the clinical data available.

Impact of Mitral Regurgitation on Clinical Outcomes After Transcatheter Aortic Valve Implantation

Severe aortic stenosis (AS) and mitral regurgitation (MR) are the two most common valvular lesions referred for surgical intervention in Europe and frequently co-exist. In patients with both severe AS and significant MR referred for surgical aortic valve replacement (SAVR), a concomitant mitral valve intervention is typically performed if the MR is severe, despite the higher associated perioperative risk. The management of moderate MR among SAVR patients is controversial and depends on a number of factors including MR aetiology (i.e., organic versus functional MR), feasibility of repair and patient risk profile. Moderate or severe MR is present in up to one-third of patients undergoing transcatheter aortic valve implantation (TAVI), is mainly of functional aetiology and is typically left untreated. Although data are conflicting, a growing body of evidence suggests that significant MR exerts an adverse effect on both short- and long-term clinical outcomes after TAVI. Moderate or severe MR improves in just over half of patients following TAVI and recent data suggest MR is more likely to improve among patients receiving a balloon-expandable as compared with a self-expandable transcatheter heart valve.

Coexisting Mitral Regurgitation Impairs Survival After Transcatheter Aortic Valve Implantation

BACKGROUND

It remains unclear whether coexisting and untreated mitral regurgitation (MR) affects survival after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS). To summarize contemporary evidence, we performed the first metaanalysis of adjusted observational studies reporting post-TAVI mortality in patients with various grades of MR.

METHODS

MEDLINE and EMBASE were searched until February 2015, with a bibliographic review of secondary sources. Eligible studies were observational studies enrolling patients undergoing TAVI for AS and reporting adjusted odds ratios (ORs), hazard ratios (HRs), or both for early (30-day or in-hospital) all-cause mortality, overall all-cause mortality, or both in patients with apparent (significant) versus unapparent (nonsignificant) MR as outcomes.

RESULTS

Sixteen eligible studies enrolling a total of 13,672 patients undergoing TAVI for AS were identified and included. Pooled analyses of eight studies (representing 9,356 patients) and 14 studies (representing 7,405 patients) respectively demonstrated a statistically significant increase in early (OR 2.17; 95% confidence interval [CI] 1.50 to 3.14; p < 0.0001) and overall all-cause mortality (HR 1.81; 95% CI 1.37 to 2.40; p < 0.0001) in patients with apparent relative to unapparent MR. The exclusion of any single study from the analyses did not substantively alter the overall results of our analyses, and there was no evidence of significant publication bias.

CONCLUSIONS

Coexisting and untreated apparent (usually moderate or severe) MR appears to be associated with an increase in both early and overall mortality after TAVI for AS.

5-Year Outcomes After Transcatheter Aortic Valve Implantation With CoreValve Prosthesis

OBJECTIVES

The purpose of this analysis was to assess 5-year outcomes of transcatheter aortic valve implantation (TAVI) using the current technology of the self-expanding CoreValve prosthesis (Medtronic Inc., Minneapolis, Minnesota).

BACKGROUND

There is a paucity of evidence on long-term durability of currently available transcatheter heart valves.

METHODS

Starting in June 2007, all consecutive patients with severe aortic stenosis undergoing TAVI with the third-generation 18-F CoreValve device in 8 Italian centers were prospectively included in the ClinicalService Project. For the purposes of this study, we included only consecutive patients with 5-year follow-up data available (n = 353) treated from June 2007 to August 2009. All outcomes were reported according to VARC (Valve Academic Research Consortium)-1 criteria.

RESULTS

All-cause mortality rates at 1, 2, 3, 4, and 5 years were 21%, 29%, 38%, 48%, and 55.0%, respectively. Cardiovascular mortality rates at 1, 2, 3, 4, and 5 years were 10%, 14%, 19%, 23%, and 28.0%, respectively. The overall neurological event rate at 5 years was 7.5%, of which more than two-thirds occurred early after the procedure. During follow-up, there were 241 rehospitalizations for cardiovascular reasons in 164 (46%) patients. Among all rehospitalizations, acute heart failure was the most frequently reported (42.7%), followed by requirement of permanent pacemaker implantation (17.4%). On echocardiography, mean transaortic gradients decreased from 55.6 ± 16.8 mm Hg (pre-TAVI) to 12.8 ± 10.9 mm Hg (5-year post-TAVI) (p < 0.001). Late prosthesis failure occurred in 5 cases (1.4%); among these, redo TAVI was successfully carried out in 2 patients (0.6%) presenting with symptomatic prosthesis restenosis. The remaining 3 cases of prosthesis failure did not undergo further invasive interventions. Ten patients (2.8%) showed late mild stenosis with a mean transaortic gradient ranging from 20 to 40 mm Hg. No other cases of structural or nonstructural valvular deterioration were observed. Valve thrombosis or late valve embolization were not reported.

CONCLUSIONS

TAVI with the currently adopted CoreValve generation was associated with sustained clinical outcomes up to 5-year follow-up, with a low rate (1.4%) of significant prosthetic valve degeneration. The procedure appears to be an adequate and lasting resolution of aortic stenosis in selected high-risk patients.

Aortic stenosis and mitral regurgitation: implications for transcatheter valve treatment

Moderate or severe mitral regurgitation (MR) is a common finding in patients with severe aortic stenosis (AS). The combination may be a relative indication for double valve surgery, particularly when MR is severe, degenerative, associated with left atrial dilation, chronic atrial fibrillation, or mitral annular calcium. However, in patients for whom open surgery is not desirable, TAVI may provide a reasonable therapeutic strategy with an expectation in selected patients that MR may improve, be better tolerated, or be amenable to staged transcatheter mitral interventions. In this paper, we briefly review the surgical experience with concomitant AS and MR and discuss the potential implications of transcatheter-based heart valve techniques in this patient group.

Significant mitral regurgitation left untreated at the time of aortic valve replacement: a comprehensive review of a frequent entity in the transcatheter aortic valve replacement era

Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients.

Interplay between mitral regurgitation and transcatheter aortic valve replacement with the CoreValve Revalving System: a multicenter registry

BACKGROUND

Little is known of the prognostic significance of mitral regurgitation (MR) on transcatheter aortic valve replacement (TAVR), the impact of TAVR on MR severity, and the variables associated with possible post-TAVR improvement in MR. We evaluated these issues in a multicenter registry of patients undergoing CoreValve Revalving System-TAVR.

METHODS AND RESULTS

Among 1007 consecutive patients, 670 (66.5%), 243 (24.1%), and 94 (9.3%) presented with no/mild, moderate, and severe MR, respectively. At 1 month after TAVR, patients with severe or moderate MR showed comparable mortality rates (odds ratio, 1.1; 95% confidence interval [95% CI], 0.7-1.55; P=0.2), but both were significantly higher compared with patients with mild/no MR (odds ratio, 2.2; 95% CI, 1.78-3.28; P<0.001; and odds ratio, 1.9; 95% CI, 1.1-3.3; P=0.02, respectively). One-year mortality was also similar between patients with severe and those with moderate MR (hazard ratio, 1.4; 95% CI, 0.94-2.4; P=0.06) and still significantly higher compared with patients with mild/no MR (hazard ratio, 1.7; 95% CI, 1.2-3.41; P<0.001; and hazard ratio, 1.4; 95% CI, 1.2-2.2; P=0.03, respectively). Severe pulmonary hypertension, atrial fibrillation, and MR more than mild, but not an improvement of ≥1 grade in MR severity, were independent predictors of mortality at 1 year. At 1 year, an improved MR was observed in 47% and 35% of patients with severe and moderate MR, respectively. The rate of low implantation was consistent across groups with improved, unchanged, or worsened MR. A functional type of MR and the absence of severe pulmonary hypertension and atrial fibrillation independently predicted the improvement in MR severity.

CONCLUSIONS

Baseline MR greater than mild is associated with higher mortality after CoreValve Revalving System-TAVR. A significant improvement in MR was more likely in patients with functional MR and without severe pulmonary hypertension or atrial fibrillation. The improvement in MR did not independently predict mortality.

Staged total percutaneous treatment of aortic valve pathology and mitral regurgitation: institutional experience

OBJECTIVES

To summarize our single Institution experience with staged total percutaneous management of aorto-mitral pathology.

BACKGROUND

Percutaneous treatment of aortic valve stenosis (AVS) and mitral valve regurgitation (MVR) has been recently proposed for patients at high surgical risk.

METHODS

Data concerning consecutive patients undergoing percutaneous transcatheter AV implantation (TAVI) followed by MV repair with MitraClip® were prospectively collected and analyzed.

RESULTS

From January 2010 to February 2012 a total of 254 patients were referred to undergo TAVI in our Institution. Seventeen (6.7%) had preoperative severe MVR that remained unchanged after TAVI. Due to exacerbation of symptoms 12 patients were subsequently submitted to MV repair with the MitraClip® device. Mean age was 79 years (72-86 years), median Ambler score was 30.1 (17.2-42.6) and EuroSCORE 22.3 (10.2-48.6). Procedural success rate was 100%. Postprocedural hospitalization was 7.1 ± 2.7 and 4.6 ± 0.9 days after TAVI and MV repair, respectively. Six months follow-up echocardiography confirms improvement in LV-EF (37.2 ± 9.9 vs. 43.5 ± 10.7, P < 0.0001). No patient presents MVR exceeding grade I(+) or prosthetic aortic insufficiency > I grade and all patients experienced an improvement in functional status.

CONCLUSIONS

Percutaneous treatment of AVS and MVR is feasible and safe. A tailored approach should be considered to treat firstly the AVS and subsequently the MVR when severe MV dysfunction and symptoms persist. Short-term durability of this combined percutaneous approach seems encouraging and justifies the economical burden to treat patients that have no other option.

Transcatheter aortic valve replacement: outcomes of patients with moderate or severe mitral regurgitation

OBJECTIVES

The aim of this study was to evaluate the impact of mitral regurgitation (MR) on outcomes after transcatheter aortic valve replacement (TAVR) and the impact of TAVR on MR.

BACKGROUND

Little is known of the influence of MR on outcomes after TAVR.

METHODS

The outcomes of patients with mild or less (n = 319), moderate (n = 89), and severe (n = 43) MR were evaluated after TAVR at 2 Canadian centers.

RESULTS

Patients with moderate or severe MR had a higher mortality rate than those with mild or less MR during the 30 days after TAVR (adjusted hazard ratio: 2.10; 95% confidence interval: 1.12 to 3.94; p = 0.02). However, the mortality rates after 30 days were similar (adjusted hazard ratio: 0.82; 95% confidence interval: 0.50 to 1.34; p = 0.42). One year after TAVR, moderate MR had improved in 58%, remained moderate in 17%, and worsened to severe in 1%, and 24% of patients had died. Severe MR had improved in 49% and remained severe in 16%, and 35% of patients had died. Multivariate predictors of improved MR at 1 year (vs. unchanged MR, worse MR, or death) were a mean transaortic gradient ≥ 40 mm Hg, functional (as opposed to structural) MR, the absence of pulmonary hypertension, and the absence of atrial fibrillation.

CONCLUSIONS

Moderate or severe MR in patients undergoing TAVR is associated with a higher early, but not late, mortality rate. At 1-year follow-up, MR was improved in 55% of patients with moderate or severe MR at baseline. Improvement was more likely in patients with high transaortic gradients, with functional MR, without pulmonary hypertension and without atrial fibrillation.

Bivalvular transcatheter treatment of high-surgical-risk patients with coexisting severe aortic stenosis and significant mitral regurgitation

BACKGROUND

In inoperable or high-surgical-risk patients, transcatheter aortic valve replacement (TAVR) and repair of the mitral valve using the MitraClip have emerged as novel treatment strategies. We sought to assess the feasibility and effectiveness of bivalvular transcatheter therapy in patients with coexisting aortic stenosis and mitral regurgitation.

METHODS

Out of 285 patients treated with TAVR and 226 patients who underwent MitraClip therapy at our institution, 11 patients (78 ± 6years, 9 men [82%]) received both therapies. TAVR preceded MitraClip therapy in 10 patients, with 3 patients undergoing both interventions in a single session.

RESULTS

TAVR via transapical (n = 6) or transfemoral (n = 5) access utilized the Sapien/Sapien XT and CoreValve prostheses in 7 and 4 patients, respectively. All TAVR procedures were successful, with significant increases in effective aortic orifice area and decreases in mean transvalvular pressure gradient. MitraClip therapy succeeded in reducing MR severity to <2+ in 10 patients. Periprocedurally, 1 patient sustained a stroke. At a median of 208 days, 2 patients were in NYHA functional class II, with only 1 patient improved from before TAVR, and 6 patients were in class III (improvement in 1). Four patients had died at a median of 60 days after MitraClip therapy.

CONCLUSION

Bivalvular transcatheter treatment of patients with coexisting aortic stenosis and MR is technically feasible, even in a single session. Given the low prevalence of midterm functional improvement, factors predictive of clinical benefit from catheter-based double-valve intervention remain to be determined.