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Henrique Rangel R, Christoph Voran J, Seoudy H, Villinger T, Lutter G, Puehler T, Kreidel F, Frank J, Salem M, Frank D, Saad M. Transcatheter aortic valve replacement in patients with severe aortic valve stenosis and concomitant mitral valve regurgitation - 5 years follow-up. IJC HEART & VASCULATURE 2024; 53:101416. [PMID: 38854408 PMCID: PMC11157207 DOI: 10.1016/j.ijcha.2024.101416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 06/11/2024]
Abstract
Objectives To investigate the change in severity of mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR) and its effect on 5-year mortality. Background There is inconsistency in literature on pre-existing MR influencing long-term survival in patients who undergo TAVR. Methods Patients who underwent TAVR at the University Hospital Schleswig-Holstein (USKH) Campus Kiel between March 2009 and February 2018 have been enrolled. Echocardiography determined the degree of MR before and within 7 days after TAVR. Patients were divided into two groups according to their MR at baseline: MR-grade ≤ 2 (non-relevant MR, nr-MR) and baseline MR-grade > 2 (relevant MR, r-MR). Primary endpoint was a composite of MR baseline influence on mortality and MR reduction and its' impact on mortality. Results A total of 820 patients (642 nr-MR and 178 in r-MR) were included in this study. Of these, 167 patients showed an improvement in MR-grade. Thereof 106 (63.5 %) referred to r-MR with a significant decrease in mean MR-grade (p < 0.01). Systolic pulmonary artery pressure (sPAP) (p < 0.01) and NT-proBNP (p = 0.03) decreased in patients who had an improvement. There was no significant difference in 5-year mortality for MR at baseline (p = 0.35) or reduction in mortality for r-MR patients with an MR improvement compared to patients with worsening or equal MR status (p = 0.80). Conclusion In patients undergoing TAVR, 63.5 % of patients with MR-grade ≥ 2 at baseline showed an improvement of grade of MR after TAVR with reduction of their sPAP and NT-proBNP values but there was no significant difference in mortality.
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Affiliation(s)
- Rafael Henrique Rangel
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jakob Christoph Voran
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg, Kiel, Lübeck, Germany
| | - Hatim Seoudy
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg, Kiel, Lübeck, Germany
| | - Theresa Villinger
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - G. Lutter
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg, Kiel, Lübeck, Germany
- Department of Cardiac and Vascular Surgery, University Clinical Center Schleswig-Holstein (UKSH), Kiel, Germany
| | - T. Puehler
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg, Kiel, Lübeck, Germany
- Department of Cardiac and Vascular Surgery, University Clinical Center Schleswig-Holstein (UKSH), Kiel, Germany
| | - Felix Kreidel
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Johanne Frank
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg, Kiel, Lübeck, Germany
| | - Mostafa Salem
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Derk Frank
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg, Kiel, Lübeck, Germany
| | - Mohammed Saad
- Department of Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Polizzi G, Campos K, Coulter SA. Mitral regurgitation carries greater prognostic significance than mitral stenosis in patients undergoing transcatheter aortic valve replacement. J Cardiovasc Med (Hagerstown) 2024; 25:529-538. [PMID: 38829939 DOI: 10.2459/jcm.0000000000001629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
AIMS This study assessed the outcomes of concomitant mitral valve disease and severe aortic stenosis in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS Echocardiographic data of 813 patients with severe aortic stenosis undergoing transfemoral TAVR were collected, and clinical outcomes were analyzed for individuals with mitral stenosis and mitral regurgitation. RESULTS The final cohort includes 788 patients with severe calcific aortic stenosis. Among single parameters of mitral stenosis, a smaller baseline mitral valve area (MVA) by the continuity equation and higher postprocedural mean mitral gradients (MMG) were associated with an increased risk of death at 1 year (P-values 0.02 and <0.01, respectively), but no correlation with outcomes was demonstrated after multivariate adjustment for major prognosticators. Mitral stenosis (based on MVA + MMG) was not associated with complications or mortality. Mitral regurgitation was present in 94.6% of the population at baseline and regressed by at least one grade post-TAVR in 28% of the patients. The improvement in mitral regurgitation was associated with a greater prosthetic effective orifice area (P-value 0.03). Significant (at least moderate) residual mitral regurgitation was correlated with short-term complications and shown to be an independent predictor of 1-year mortality (P-value 0.02, odds ratio (OR) 5.37, confidence interval 1.34-21.5). CONCLUSION Mitral regurgitation has a greater impact on TAVR patients than mitral stenosis as assessed by functional methods.
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Affiliation(s)
- Giovanni Polizzi
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
| | - Karla Campos
- Center for Women's Heart and Vascular Health, The Texas Heart Institute, Houston, TX, USA
| | - Stephanie Alyse Coulter
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
- Center for Women's Heart and Vascular Health, The Texas Heart Institute, Houston, TX, USA
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Alaour B, Nakase M, Pilgrim T. Combined Significant Aortic Stenosis and Mitral Regurgitation: Challenges in Timing and Type of Intervention. Can J Cardiol 2024; 40:235-249. [PMID: 37931671 DOI: 10.1016/j.cjca.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023] Open
Abstract
In this narrative review, we aim to summarize the literature surrounding the assessment and management of the common, yet understudied combination of aortic stenosis (AS) and mitral regurgitation (MR), the components of which are complexly inter-related and interdependent from diagnostic, prognostic, and therapeutic perspectives. The hemodynamic interdependency of AS and MR confounds the assessment of the severity of each valve disease, thus underscoring the importance of a multimodal approach integrating valvular and extravalvular indicators of severity. A large body of literature suggests that baseline MR is associated with reduced survival post aortic valve (AV) intervention and that regression of MR post-AV intervention confers a mortality benefit. Functional MR is more likely to regress after AV intervention than primary MR. The respective natural courses of the 2 valve diseases are not synchronized; therefore, significant AS and MR at or above the respective threshold for intervention might not coincide. Surgery is primarily a 1-stop-shop procedure because of a considerable perioperative risk of repeat interventions, whereas transcatheter treatment modalities allow for a more tailored timing of intervention with reassessment of concomitant MR after AV replacement and a potential staged intervention in the absence of MR regression. In summary, AS and MR, when combined, are interlaced into a complex hemodynamic, diagnostic, and prognostic synergy, with important therapeutic implications. Contemporary approaches should consider stepwise intervention by exploiting the advantage of transcatheter options. However, evidence is needed to demonstrate the efficacy of different timing and therapeutic options.
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Masaaki Nakase
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Asher SR, Ong CS, Malapero RJ, Heydarpour M, Malzberg GW, Shahram JT, Nguyen TB, Shook DC, Shernan SK, Shekar P, Kaneko T, Citro R, Muehlschlegel JD, Body SC. Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery. Front Cardiovasc Med 2023; 10:1202174. [PMID: 37840960 PMCID: PMC10570832 DOI: 10.3389/fcvm.2023.1202174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival. Methods Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity. Results Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not. Conclusions These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.
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Affiliation(s)
- Shyamal R. Asher
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, United States
| | - Chin Siang Ong
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Raymond J. Malapero
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Mahyar Heydarpour
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Gregory W. Malzberg
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Jasmine T. Shahram
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Thy B. Nguyen
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Douglas C. Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Stanton K. Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Prem Shekar
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Rodolfo Citro
- Cardio-Thoracic-Vascular Department, University Hospital—San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy
| | - Jochen D. Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Simon C. Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, United States
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Impact of Transcatheter Aortic Valve Implantation Among Patients With Co-existing Mild to Moderate Mitral Regurgitation. Am J Cardiol 2022; 177:84-89. [PMID: 35732551 DOI: 10.1016/j.amjcard.2022.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022]
Abstract
A subset of patients with severe aortic stenosis (AS) who are who underwent transcatheter aortic valve implantation (TAVI) also has mitral regurgitation (MR). Clinical outcomes in these patients with combined MR and AS have varied. The purpose of this study was to assess clinical outcomes and echocardiographic outcomes after TAVI in patients with preprocedural MR. A retrospective chart review from March 2018 to June 2020 identified all TAVI patients. Patients were assigned an MR class of mild, moderate, or severe based upon pre-TAVI transthoracic echocardiogram (TTE). Patients were excluded if they were discharged from the hospital and did not have a 6-month follow-up after TAVI. Clinical outcomes at 6 months included all-cause mortality, major adverse cardiovascular events, clinically significant bleeding, changes in ejection fraction (EF) category, and changes in MR severity. Of 118 included patients (age 76 ± 10 years, 79% male, 46% White), 33% had MR, with 26% being mild and 7% moderate MR. Before TAVI, AS + MR patients were more likely to have a reduced EF (<50%) by category compared with those with AS only (33.3% vs 8.8%, p = 0.01) but were more likely to show an increase in EF by category after TAVI (19.4% vs 5.5%, p = 0.039). No significant differences were observed between the 2 groups in terms of all-cause mortality (12.8 vs 5.1%, p = 0.14), major adverse cardiovascular events (17.9 vs 8.9%, p = 0.15), or clinically significant bleeding (10.3 vs 6.3%, p = 0.45). Patients with AS and co-existing MR experienced similar clinical outcomes at 6 months to those with AS only after TAVI. They were more likely to show increases in EF category 6 months after valve implantation. Our results support the conclusion that in addition to treating the aortic valve, TAVI also potentially benefits left ventricular function in the setting of mild or moderate MR.
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Patel KP, Treibel TA, Scully PR, Fertleman M, Searle S, Davis D, Moon JC, Mullen MJ. Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity. Interv Cardiol 2022; 17:e01. [PMID: 35111240 PMCID: PMC8790725 DOI: 10.15420/icr.2021.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/05/2021] [Indexed: 12/12/2022] Open
Abstract
Although transcatheter aortic valve implantation (TAVI) has revolutionised the landscape of treatment for aortic stenosis, there exists a cohort of patients where TAVI is deemed futile. Among the pivotal high-risk trials, one-third to half of patients either died or received no symptomatic benefit from the procedure at 1 year. Futility of TAVI results in the unnecessary exposure of risk for patients and inefficient resource utilisation for healthcare services. Several cardiac and extra-cardiac conditions and frailty increase the risk of mortality despite TAVI. Among the survivors, these comorbidities can inhibit improvements in symptoms and quality of life. However, certain conditions are reversible with TAVI (e.g. functional mitral regurgitation), attenuating the risk and improving outcomes. Quantification of disease severity, identification of reversible factors and a systematic evaluation of frailty can substantially improve risk stratification and outcomes. This review examines the contribution of pre-existing comorbidities towards futility in TAVI and suggests a systematic approach to guide patient evaluation.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Paul R Scully
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Michael Fertleman
- Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London London, UK
| | - Samuel Searle
- MRC Unit for Lifelong Health and Ageing, University College London London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London London, UK
| | - James C Moon
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Michael J Mullen
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
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7
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OUP accepted manuscript. Eur Heart J 2022; 43:2729-2750. [DOI: 10.1093/eurheartj/ehac105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/22/2022] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
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Karacop HB, Karacop E. Improvement of Pulmonary Function in Heart Failure Patients with Restrictive Patterns Undergoing Transcatheter Aortic Valve Replacement. Int J Gen Med 2021; 14:5159-5165. [PMID: 34511998 PMCID: PMC8421250 DOI: 10.2147/ijgm.s309175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022] Open
Abstract
Background This study aimed to investigate the improvement of pulmonary function in heart failure patients with restrictive patterns undergoing transcatheter aortic valve replacement (TAVR). Methods A total of 80 patients with heart failure and restrictive patterns undergoing TAVR due to severe aortic stenosis were included in this study. Spirometry and gas diffusion were assessed before and 4–6 months after TAVR. Pre- and post-TAVR measures were compared using paired t-tests. Results Spirometry demonstrated increased absolute and percentage predicted total lung capacity (TLC), forced vital capacity (FVC), residual volume (RV), forced expiratory volume in the first second (FEV1), and forced vital capacity (FVC). FEV1/FVC decreased due to a pronounced increase in FVC. Additionally, the diffusing capacity for carbon monoxide (DLCO) increased significantly. Conclusion Pulmonary function improves in heart failure patients with restrictive patterns undergoing TAVR.
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Affiliation(s)
- Handan Basel Karacop
- Bezmialem Foundation University, Faculty of Medicine, Department of Pulmonary Medicine, Istanbul, Turkey
| | - Erdem Karacop
- Bezmialem Foundation University, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
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Tirado-Conte G, McInerney A, Jimenez-Quevedo P, Carnero M, Marroquin Donday LA, De Agustin A, Witberg G, Pozo E, Islas F, Marcos-Alberca P, Cobiella J, Koronowski R, Macaya C, Rodes-Cabau J, Nombela-Franco L. Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation. Expert Rev Cardiovasc Ther 2021; 19:711-723. [PMID: 34275408 DOI: 10.1080/14779072.2021.1955347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Significant mitral regurgitation (MR) frequently coexists in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). These patients have worse clinical outcomes than those with non-significant MR, especially if MR persists after treatment of the aortic stenosis. The optimal treatment approach for this challenging high-risk population is not well defined. AREAS COVERED This review aims to present the current literature on concomitant significant MR in the TAVR population, and to provide a comprehensive algorithmic approach for clinical decision-making in this challenging cohort of patients. EXPERT OPINION Concomitant mitral and aortic valve disease is a complex clinical entity. An exhaustive and comprehensive assessment of patient's clinical characteristics and mitral valve anatomy and function is required in order to assess the surgical risk, predict the MR response after AVR and evaluate the feasibility of percutaneous MV treatment if necessary. Further developments in transcatheter techniques will expand the indications for double valve treatment in operable and inoperable patients with concomitant significant MR and aortic stenosis.
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Affiliation(s)
- Gabriela Tirado-Conte
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Angela McInerney
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Pilar Jimenez-Quevedo
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Luis A Marroquin Donday
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Alberto De Agustin
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Guy Witberg
- Department of Cardiology, Rabin Medical Centre, Petach-Tikvav, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eduardo Pozo
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Fabian Islas
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Pedro Marcos-Alberca
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Ran Koronowski
- Department of Cardiology, Rabin Medical Centre, Petach-Tikvav, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carlos Macaya
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Luis Nombela-Franco
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
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Enta Y, Miyasaka M, Taguri M, Tada N, Hata M, Watanabe Y, Naganuma T, Yamawaki M, Yamanaka F, Shirai S, Ueno H, Mizutani K, Tabata M, Takagi K, Yamamoto M, Hayashida K. Patients' characteristics and mortality in urgent/emergent/salvage transcatheter aortic valve replacement: insight from the OCEAN-TAVI registry. Open Heart 2021; 7:openhrt-2020-001467. [PMID: 33318151 PMCID: PMC7737081 DOI: 10.1136/openhrt-2020-001467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 11/30/2022] Open
Abstract
Objectives Patients’ backgrounds and clinical outcomes in urgent/emergent/salvage transcatheter aortic valve replacement (Em-TAVR) remain unclear. We investigated patient characteristics and the mortality in Em-TAVR and the predictors for the need for Em-TAVR. Methods We consecutively enrolled 1613 patients undergoing TAVR for severe aortic stenosis between October 2013 and July 2016 from the Optimised transCathEter vAlvular interventioN (OCEAN)-transcatheter aortic valve implantation (TAVI) registry. The urgency was based on the European System for Cardiac Operative Risk Evaluation II. Urgent, emergent or salvage were included with the Em-TAVR group and elective with the El-TAVR group. Results Em-TAVR was observed in 87 (5.4%) patients. A higher Clinical Frailty Scale (CFS), peripheral artery disease (PAD), hypoalbuminaemia, reduced left ventricular ejection fraction (LVEF) and preoperative at least moderate mitral regurgitation (MR) predicted the need for the Em-TAVR by the multivariate logistic regression analysis. The Em-TAVR group had the higher Society of Thoracic Surgeons Score (13.7 (IQR 8.2–21.0) vs 6.5 (IQR 4.6–9.2); p<0.001) and higher 30-day mortality (9.2% vs 1.3%; p<0.001) than the El-TAVR group. Accordingly, Kaplan-Meier analysis showed that the cumulative mortality was higher in the Em-TAVR group than that in the El-TAVR group (log-rank; p<0.001). However, Em-TAVR did not predict mortality in the multivariate Cox regression analysis. Conclusions Em-TAVR was performed in 5.4% of patients. Higher CFS, PAD, hypoalbuminaemia, reduced LVEF and preprocedural MR predicted the need for Em-TAVR. Em-TAVR was not a predictor for mortality in the multivariate analysis, suggesting that it is a reasonable treatment option.
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Affiliation(s)
- Yusuke Enta
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Masaki Miyasaka
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Masataka Taguri
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan.,Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Norio Tada
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Masaki Hata
- Cardiovascular Center, Sendai Kousei Hospital, Sendai, Miyagi, Japan
| | - Yusuke Watanabe
- Cardiology, Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Toru Naganuma
- Cardiology, New Tokyo Hospital, Matsudo, Chiba, Japan
| | - Masahiro Yamawaki
- Cardiology, Saiseikai Yokohama-City Eastern Hospital, Yokohama, Kanagawa, Japan
| | - Futoshi Yamanaka
- Cardiology, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Shinichi Shirai
- Cardiology, Kokura Memorial Hospital, Kitakyusyu, Fukuoka, Japan
| | - Hiroshi Ueno
- Cardiology, Toyama University Hospital, Toyama, Toyama, Japan
| | - Kazuki Mizutani
- Cardiovascular Medicine, Osaka City General Hospital, Osaka, Osaka, Japan
| | - Minoru Tabata
- Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Kensuke Takagi
- Cardiology, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
| | - Masanori Yamamoto
- Cardiology, Toyohashi Heart Center, Toyohashi, Aichi, Japan.,Cardiology, Nagoya Heart Center, Nagoya, Aichi, Japan
| | - Kentaro Hayashida
- Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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da Cunha LDCBP, Guerios EE, da Cunha CLP, Carvalho LA, Lemos P, Sarmento-Leite R, Abizaid AA, Mangione JA, Oliveira AD, Siciliano A, Esteves V, de Brito FS. Relationship between Mitral Regurgitation and Transcatheter Aortic Valve Implantation: a Multi-Institutional Follow-up Study. Arq Bras Cardiol 2021; 116:1059-1069. [PMID: 34133587 PMCID: PMC8288547 DOI: 10.36660/abc.20190772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 05/23/2020] [Accepted: 06/16/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Mitral regurgitation (MR) is prevalent in patients undergoing transcatheter aortic valve implantation (TAVI). There are some controversies about the prognostic impact of MR in survival of TAVI patients. OBJECTIVE To examine the relationship between TAVI and MR in a patient population from the Brazilian TAVI Registry. METHODS Seven hundred and ninety-five patients from the Brazilian TAVI Registry were divided at baseline, discharge, and follow-up according to their MR grade as follows: absent/mild (AMMR) or moderate/severe (MSMR). They were subsequently regrouped according to their immediate and late changes in MR severity after TAVI as follows: no change, improved, or worsened MR. Predictors and prognostic impact on baseline as well as changes in MR severity were analyzed. Statistical significance was set at p < 0.05. RESULTS Baseline MSMR was present in 19.3% of patients and was a predictor of increased late mortality. Immediately after TAVI, 47.4 % of cases improved to AMMR, predicted by a higher Society of Thoracic Surgeons score and a higher grade of baseline aortic regurgitation. Upon follow-up, 9.2% of cases of AMMR worsened to MSMR, whereas 36.8% of cases of MSMR improved to AMMR. Lower baseline left ventricular ejection fraction (LVEF) and improvement in LVEF at follow-up were predictors of MR improvement. Progressive worsening of MR upon follow-up was an independent predictor of higher late mortality after TAVI (p = 0.005). CONCLUSIONS Baseline MSMR predicts late mortality after TAVI. Lower LVEF and improved LVEF at follow-up predict MR improvement after TAVI. Progressive worsening of MR severity at follow-up is an independent predictor of late mortality, which is a rare finding in the literature.
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Affiliation(s)
| | - Enio Eduardo Guerios
- Universidade Federal do ParanáHospital de ClínicasCuritibaPRBrasil Universidade Federal do Paraná - Hospital de Clínicas - UFPR, Curitiba , PR - Brasil
| | - Claudio Leinig Pereira da Cunha
- Universidade Federal do ParanáHospital de ClínicasCuritibaPRBrasil Universidade Federal do Paraná - Hospital de Clínicas - UFPR, Curitiba , PR - Brasil
| | - Luiz A. Carvalho
- Hospital Pró-CardíacoRio de JaneiroRJBrasil Hospital Pró-Cardíaco , Rio de Janeiro , RJ - Brasil
| | - Pedro Lemos
- Hospital Israelita Albert EinsteinSão PauloSPBrasil Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - Rogério Sarmento-Leite
- Instituto de CardiologiaPorto AlegreRSBrasil Instituto de Cardiologia , Porto Alegre , RS - Brasil
| | - Alexandre A. Abizaid
- Hospital Israelita Albert EinsteinSão PauloSPBrasil Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - José Antonio Mangione
- Hospital Beneficência Portuguesa de São PauloSão PauloSPBrasil Hospital Beneficência Portuguesa de São Paulo , São Paulo , SP - Brasil
| | | | - Alexandre Siciliano
- Hospital Israelita Albert EinsteinSão PauloSPBrasil Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - Vinicius Esteves
- Rede D’Or São LuizSão PauloSPBrasil Rede D’Or São Luiz , São Paulo , SP - Brasil
| | - Fábio Sândoli de Brito
- Universidade de São PauloInstituto do CoraçãoSão PauloSPBrasil Universidade de São Paulo Instituto do Coração , São Paulo , SP - Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP - Brasil
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12
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Aranzulla TC, Musumeci G. Remove the obstacle and get into the flow! Catheter Cardiovasc Interv 2020; 96:979-980. [PMID: 33085196 DOI: 10.1002/ccd.29296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/06/2022]
Affiliation(s)
| | - Giuseppe Musumeci
- Cardiology Department, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
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13
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Miceli A, Di Bacco L, Donatelli F, Glauber M. Can we solve two problems with a TAVR? Int J Cardiol 2020; 322:95-96. [PMID: 32911001 DOI: 10.1016/j.ijcard.2020.08.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Antonio Miceli
- Minimally invasive Cardiac Surgery Department, Istituto Clinico Sant'Ambrogio, Italy.
| | - Lorenzo Di Bacco
- Minimally invasive Cardiac Surgery Department, Istituto Clinico Sant'Ambrogio, Italy
| | - Francesco Donatelli
- Chair of Cardiac Surgery, Department of Clinical and Community Sciences, University of Milan, Italy
| | - Mattia Glauber
- Minimally invasive Cardiac Surgery Department, Istituto Clinico Sant'Ambrogio, Italy
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14
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Khan F, Okuno T, Malebranche D, Lanz J, Praz F, Stortecky S, Windecker S, Pilgrim T. Transcatheter Aortic Valve Replacement in Patients With Multivalvular Heart Disease. JACC Cardiovasc Interv 2020; 13:1503-1514. [DOI: 10.1016/j.jcin.2020.03.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 12/21/2022]
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15
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Miura M, Yamaji K, Shirai S, Hayashi M, Kawaguchi T, Arai Y, Sakaguchi G, Ando K, Naganuma T, Mizutani K, Araki M, Tada N, Yamanaka F, Tabata M, Ueno H, Takagi K, Higashimori A, Watanabe Y, Yamamoto M, Hayashida K. Clinical Impact of Preprocedural Moderate or Severe Mitral Regurgitation on Outcomes After Transcatheter Aortic Valve Replacement. Can J Cardiol 2020; 36:1112-1120. [PMID: 32470334 DOI: 10.1016/j.cjca.2019.12.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/26/2019] [Accepted: 12/16/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The influence of improved mitral regurgitation (MR) on the outcomes of transcatheter aortic valve replacement (TAVR) is unknown. Our aim was to determine the impact of significant preprocedural MR and the improvement of MR after TAVR. METHODS A population of 1587 patients from the Optimized Catheter Valvular Intervention Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry were evaluated. Preprocedural MR was mild or less in 1443 patients (90.9%) and moderate or severe in 144 patients (9.1%). RESULTS Moderate or severe MR was associated with increased risk for all-cause mortality at 1 year (adjusted hazard ratio, 1.85; 95% confidence interval [CI], 1.20-2.84; P = 0.005) and 2 years (adjusted hazard ratio, 1.64; 95% CI, 1.15-2.34; P = 0.007). At 6 months after TAVR, the MR grade improved in 77.4% of the patients with moderate or severe baseline MR. Multivariate analysis showed that the absence of previous myocardial infarction (odds ratio, 8.00; 95% CI, 1.74-36.8; P = 0.008) and beta-blocker use at baseline (odds ratio, 2.71; 95% CI, 1.09-6.70; P = 0.031) were independently associated with improved MR at 6 months (vs unchanged, worsened MR, or death). Patients with improved MR had a significantly lower rate of midterm readmission for heart failure (11.6%) than those with unchanged or worsened MR (30.8%, P = 0.007). CONCLUSIONS Moderate or severe MR was associated with increased risk of all-cause mortality 2 years after TAVR. Moderate or severe baseline MR was improved in most patients at 6 months after TAVR. Patients with unchanged or worsened MR had an increased rate of readmission for heart failure.
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Affiliation(s)
- Mizuki Miura
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.
| | - Kyohei Yamaji
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Masaomi Hayashi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | | | - Yoshio Arai
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Genichi Sakaguchi
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Kazuki Mizutani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Motoharu Araki
- Department of Cardiology, Saiseikai Yokohama-City Eastern Hospital, Yokohama, Japan
| | - Norio Tada
- Cardiovascular Center, Sendai Kosei Hospital, Sendai, Japan
| | - Futoshi Yamanaka
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Urayasu, Japan
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kensuke Takagi
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | | | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | | | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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16
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Nappi F, Nenna A, Timofeeva I, Mihos C, Gentile F, Chello M. Mitral regurgitation after transcatheter aortic valve replacement. J Thorac Dis 2020; 12:2926-2935. [PMID: 32642205 PMCID: PMC7330403 DOI: 10.21037/jtd.2020.01.69] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patients undergoing transcatheter aortic valve replacement (TAVR) might have an associated significant MR that can potentially lead to left ventricular (LV) failure after procedure. Considering the specific alterations in the mitral valve in TAVR scenario and the widespread use of TAVR in recent years, it appears important to know and understand the anatomical, functional and clinical implications to develop adequate strategies for the future. Patients with severe mitral regurgitation (MR) have been generally excluded from randomized clinical trials, making poor the impact that associated MR can have on clinical outcomes after TAVR. Several factors must be considered whose presence influences the severity of MR. For example, the elevated prevalence of coronary disease with consequent ischemic MR may account for LV dilation observed at the end stage of aortic stenosis. Evidence randomized studies and registries suggests that the rate of concomitant moderate-to-severe MR in patients undergoing TAVR oscillates between 2% and 33%, and patients with moderate to severe MR may have hemodynamic frailty with clinical deterioration during mechanical intervention. Short- and long-term outcomes, including cardiac mortality, appear to be influenced by the existence of preoperative moderate-to-severe MR or by the postprocedural worsening of mild MR, generally due to adverse LV remodeling. The incidence and the prognostic effect of concomitant MR in patients undergoing TAVR requires specific attention as might trigger adjunctive strategy treatment which should be carefully evaluated in clinical trials.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Irina Timofeeva
- Department of Imaging, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Christos Mihos
- Division of Cardiology, Columbia University, Mount Sinai Heart Institute, Miami Beach, FL USA
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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17
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Krittanawong C, Kumar A, Wang Z, Johnson KW, Rastogi U, Narasimhan B, Kaplin S, Virk HUH, Baber U, Tang W, Lansky AJ, Stone GW. Predictors of In-Hospital Mortality after Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 125:251-257. [PMID: 31759517 DOI: 10.1016/j.amjcard.2019.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
The development of aortic valve stenosis is strongly associated with older adults. Patients who undergo transcatheter aortic valve implantation (TAVI) for severe aortic stenosis frequently have heart failure (HF). We investigated the predictors of mortality after TAVI according to the presence of HF, and specifically HF with preserved ejection fraction (HFpEF) versus HF with reduced ejection fraction (HFrEF). Patients were identified from the Nationwide Inpatient Sample registry from January 2011 to September 2015 using the ICD-9 codes. Patients with HF who underwent TAVI were classified according to whether they were diagnosed with HFrEF or HFpEF. The principal outcome of interest was in-hospital mortality. Multivariable analysis was used to adjust for potential baseline confounders. Among 11,609 patients undergoing TAVI, 6,368 (54.9%) had baseline HF, including 4,290 (67.4%) with HFpEF and 2,078 (32.6%) with HFrEF. In TAVI patients with HF, in-hospital mortality was also not significantly different in those with HFrEF compared with HFpEF (3.66% vs 3.17%, respectively; adjusted odds ratio 1.14, 95% confidence interval 0.84 to 1.53; p = 0.38). Polyvalvular heart disease was an additional independent predictor of in-hospital mortality in HFrEF, whereas age, liver disease, and the absence of depression and anemia were additional independent predictors of mortality in HFpEF. In conclusion, baseline HF in patients undergoing TAVI is prevalent and is more commonly due to HFpEF than HFrEF. Mortality is similar in those with HFrEF and HFpEF. Knowledge of the specific predictors of mortality after TAVI in HF patients may be useful for patient selection and prognostic guidance.
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18
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Clinical impact of post procedural mitral regurgitation after transcatheter aortic valve replacement. Int J Cardiol 2020; 299:215-221. [DOI: 10.1016/j.ijcard.2019.07.092] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/18/2019] [Accepted: 07/30/2019] [Indexed: 11/21/2022]
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19
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Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement. Int J Cardiol 2019; 294:32-36. [DOI: 10.1016/j.ijcard.2019.07.075] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/20/2019] [Accepted: 07/23/2019] [Indexed: 11/20/2022]
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20
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Outcomes of transcatheter aortic valve replacement in patients with mitral valve regurgitation. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:187-194. [PMID: 31497051 PMCID: PMC6727220 DOI: 10.5114/aic.2019.86011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/11/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Transcatheter aortic valve replacement (TAVR) is currently considered a class I indication for patients with severe symptomatic aortic stenosis and high/prohibitive surgical risk. Aim We describe the effect of concomitant mitral valve regurgitation (MR) on post-procedural TAVR outcomes. Material and methods The study population was extracted from the 2014 National Readmissions Data (NRD) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for TAVR, MR and post-procedural outcomes. Propensity matching was used to extract a control group of TAVR patients without MR (TAVR-C) to the TAVR with concomitant MR group (TAVR-MR). Study outcomes included in-hospital all-cause mortality, in-hospital post-procedural stroke, acute myocardial infarction (AMI), bleeding, mechanical complications of prosthetic valve, vascular complications (VC), need for new permanent pacemaker implantation (PPM) and 30-day readmission rates. Results A total of 1511 patients were identified in each group (mean age: 81.7 years, 49.3% male); the two groups were comparable in terms of baseline characteristics and co-morbidities. When compared to TAVR-C, TAVR-MR was associated with lower post-procedural stroke (3.5% vs. 5.2%, p = 0.03). There was no significant difference between groups in terms of all-cause mortality (4.1% vs. 4.5%, p = 0.59), AMI (3.2% vs. 2.9%, p = 0.59), bleeding (33.4% vs. 35.6%, p = 0.19), mechanical complications of prosthetic valve (2.5% vs. 1.9%, p = 0.31), VC (3.2% vs. 4.4%, p = 0.06), the need for PPM (7.9% vs. 9.1%, p = 0.21) or 30-day readmission rates (19.0% vs. 19.1%, p = 0.95). Conclusions TAVR-MR was associated with lower post-procedural stroke but comparable other in-hospital outcomes and 30-day readmission rates to TAVR-C.
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21
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Chew PG, Dobson LE, Garg P, Fairbairn TA, Musa TA, Uddin A, Swoboda PP, Foley JR, Fent GJ, Brown LAE, Onciul S, Plein S, Blackman DJ, Greenwood JP. CMR quantitation of change in mitral regurgitation following transcatheter aortic valve replacement (TAVR): impact on left ventricular reverse remodeling and outcome. Int J Cardiovasc Imaging 2018; 35:161-170. [PMID: 30182320 PMCID: PMC6373302 DOI: 10.1007/s10554-018-1441-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
Current echocardiographic data reporting the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve replacement (TAVR) are conflicting. Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MR severity on cardiac reverse remodeling and patient outcome. 85 patients undergoing TAVR with CMR pre- and 6 m post-TAVR were evaluated. The CMR protocol included cines for left (LV) and right ventricular (RV) volumes, flow assessment, and myocardial scar assessment by late gadolinium enhancement (LGE). Patients were dichotomised according to CMR severity of MR fraction at baseline (‘non-significant’ vs ‘significant’) and followed up for a median duration of 3 years. Forty-two (49%) patients had ‘significant MR’ at baseline; they had similar LV and RV size and function compared to the ‘non-significant MR’ group but had greater LV mass at baseline. In those with significant MR at baseline, 77% (n = 32) had a reduction in MR post-TAVR, moving them into the ‘non-significant’ category at 6-months, with an overall reduction in MR fraction from 34 to 17% (p < 0.001). Improvement in MR was not associated with more favourable cardiac reverse remodeling when compared with the ‘non-improvers’. Significant MR at baseline was not associated with increased mortality at follow-up. Significant MR is common in patients undergoing TAVR and improves in the majority post-procedure. Improvement in MR was not associated with more favourable LV reverse remodeling and baseline MR severity was not associated with mortality.
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Affiliation(s)
- Pei G Chew
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Laura E Dobson
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Pankaj Garg
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Timothy A Fairbairn
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Tarique A Musa
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Akhlaque Uddin
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Peter P Swoboda
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - James R Foley
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Graham J Fent
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Louise A E Brown
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Sebastian Onciul
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | | | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK.
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22
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Stähli BE, Reinthaler M, Leistner DM, Landmesser U, Lauten A. Transcatheter Aortic Valve Replacement and Concomitant Mitral Regurgitation. Front Cardiovasc Med 2018; 5:74. [PMID: 29971238 PMCID: PMC6018074 DOI: 10.3389/fcvm.2018.00074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/30/2018] [Indexed: 12/24/2022] Open
Abstract
Mitral regurgitation frequently coexists in patients with severe aortic stenosis. Patients with moderate to severe mitral regurgitation at the time of transcatheter aortic valve replacement are at increased risk of future adverse events. Whether concomitant mitral regurgitation is independently associated with worse outcomes after TAVR remains a matter of debate. The optimal therapeutic strategy in these patients-TAVR with evidence-based heart failure therapy, combined TAVR and transcatheter mitral valve intervention, or staged transcatheter therapies-is ill-defined, and guideline-based recommendations in patients at increased risk for open heart surgery are lacking. Hence, a thorough evaluation of the aortic and mitral valve anatomy and function, along with an in-depth assessment of the patients' baseline risk profile, provides the basis for an individualized treatment approach. The aim of this review is therefore to give an overview of the current literature on mitral regurgitation in TAVR, focusing on different diagnostic and therapeutic strategies and optimal clinical decision making.
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Affiliation(s)
- Barbara E Stähli
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| | - David M Leistner
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Alexander Lauten
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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23
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Sannino A, Grayburn PA. Mitral regurgitation in patients with severe aortic stenosis: diagnosis and management. Heart 2017; 104:16-22. [DOI: 10.1136/heartjnl-2017-311552] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/26/2017] [Accepted: 07/05/2017] [Indexed: 11/04/2022] Open
Abstract
Severe aortic stenosis (AS) and mitral regurgitation (MR) frequently coexist. Although some observational studies have reported that moderate or severe MR is associated with higher mortality, the optimal management of such patients is still unclear. Simultaneous replacement of both aortic and mitral valves is linked to significantly higher morbidity and mortality. Recent advances in minimally invasive surgical or transcatheter therapies for MR allow for staged procedures in which surgical or transcatheter aortic valve replacement (SAVR/TAVR) is done first and MR severity re-evaluated afterwards. Current evidence suggests MR severity improves in some patients after SAVR or TAVR, depending on several factors (MR aetiology, type of valve used for TAVR, presence/absence of atrial fibrillation, residual aortic regurgitation, etc). However, as of today, the absence of randomised clinical trials does not allow for evidence-based recommendations about whether or not MR should be addressed at the time of SAVR or TAVR. A careful patient evaluation and clinical judgement are recommended to distinguish patients who might benefit from a double valve intervention from those in which MR should be left alone. The aim of this review is to report and critique the available data on this subject in order to help guide the clinical decision making in this challenging subset of patients.
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24
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Florentino TM, Bihan DL, Abizaid AAC, Cedro AV, Corrêa AP, dos Santos ARM, Souza AC, Bignoto TC, Sousa JEMR, Sousa AGDMR. Primary Mitral Valve Regurgitation Outcome in Patients With Severe Aortic Stenosis 1 Year After Transcatheter Aortic Valve Implantation: Echocardiographic Evaluation. Arq Bras Cardiol 2017; 109:0. [PMID: 28700016 PMCID: PMC5576119 DOI: 10.5935/abc.20170094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 02/06/2017] [Accepted: 03/13/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND: Mitral valve regurgitation (MR), present in up to 74% of the patients with severe aortic stenosis (AS), can be a negative prognostic factor when moderate or severe. The outcome of MR after percutaneous transcatheter aortic valve implantation (TAVI) and predictors associated with that outcome have not been well established in the literature. OBJECTIVE: To assess the outcome of primary MR in patients submitted to TAVI and to identify associated factors. METHODS: Observational study of patients with symptomatic severe AS submitted to TAVI from January 2009 to April 2015 at two specialized centers. Echocardiographic outcome was assessed with data collected before and 1 year after TAVI. RESULTS: Of the 91 patients with MR submitted to TAVI and followed up for at least 12 months, 67 (73.6%) had minimum/mild MR before the procedure and 24 (26.4%) had moderate/severe MR. Of those with minimum/mild MR, 62 (92.5%) had no change in the MR grade (p < 0.001), while 5 (7.5%) showed worsening. Of those with moderate/severe MR, 8 (33.3%) maintained the same grade and 16 (66.7%) improved it (p = 0.076). Patients with moderate/severe MR who improved MR grade had lower EuroSCORE II (p = 0.023) and STS morbidity (p = 0.027) scores, as compared to those who maintained the MR grade. CONCLUSION: MR grades change after TAVI. This study suggests a trend towards improvement in moderate/severe MR after TAVI, which was associated with lower preoperative risk scores. FUNDAMENTOS: A insuficiência valvar mitral (IM), presente em até 74% dos pacientes com estenose aórtica (EA) grave, pode representar um fator prognóstico negativo quando moderada ou importante. A evolução da IM após implante percutâneo de valva aórtica transcateter (TAVI) e preditores associados a essa evolução não estão bem estabelecidos na literatura. OBJETIVOS: Avaliar a evolução da IM primária em pacientes submetidos ao TAVI e identificar fatores associados a essa evolução. MÉTODOS: Realizou-se um estudo observacional em pacientes com EA grave sintomática, submetidos ao TAVI no período de janeiro de 2009 a abril de 2015 em dois centros especializados. Foram avaliados desfechos ecocardiográficos com dados antes e 1 ano após a intervenção. RESULTADOS: Dos 91 pacientes com IM que realizaram TAVI e tinham acompanhamento de pelo menos 12 meses, 67 (73,6%) apresentavam IM mínima ou discreta antes da realização do procedimento e 24 (26,4%), IM moderada ou grave. Entre os com IM mínima ou discreta, 62 (92,5%) não apresentaram mudança no grau de refluxo (p < 0,001) e 5 (7,5%) tiveram piora. Entre os com IM moderada ou grave, 8 (33,3%) permaneceram na mesma classe e 16 (66,7%) tiveram melhora (p = 0,076). Pacientes com IM moderada ou grave que melhoraram o grau de insuficiência apresentavam menores valores de EuroSCORE II (p = 0,023) e STS morbidade (p = 0,027), quando comparados aos que continuaram na mesma classe. CONCLUSÃO: Observou-se mudança significativa no grau de IM após realização de TAVI. Este estudo sugere uma tendência de melhora da IM moderada ou grave após TAVI, o que se associou a escores de risco pré-operatórios menos elevados.
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Affiliation(s)
| | - David Le Bihan
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP -
Brazil
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The impact of functional vs degenerative mitral regurgitation on clinical outcomes among patients undergoing transcatheter aortic valve implantation. Am Heart J 2017; 184:71-80. [PMID: 27892889 DOI: 10.1016/j.ahj.2016.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/25/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Among patients undergoing transcatheter aortic valve implantation (TAVI), concomitant mitral regurgitation (MR) has been associated with adverse prognosis. We aimed to assess long-term clinical outcomes according to MR etiology. METHODS In a single-center registry of consecutive patients undergoing TAVI, we investigated the impact of functional (FMR) vs degenerative (DMR) MR on cardiovascular (CV) mortality throughout 2years of follow-up. RESULTS Among 603 patients (mean age 82.4±5.7years, 55% female) undergoing TAVI, 149 patients had moderate or severe MR (24.7%). Functional MR and DMR were documented in 53 (36%) and 96 (64%) patients, respectively. At 2years, patients with FMR and DMR had higher rates of CV mortality (30.2% vs 32.4%) as compared with patients with no MR (14.6%; FMR vs no MR: hazard ratio [HR] 2.32, 95% CI 1.34-4.02, P=.003; DMR vs no MR: HR 2.56, 95% CI 1.66-3.96, P<.001). In adjusted analyses, DMR was associated with an increased risk of CV mortality throughout the 2-year follow-up (adjusted HR 2.21, 95% CI 1.4-3.49, P=.001) as compared with FMR (adjusted HR 1.13, 95% CI 0.59-2.18, P=.707). Relevant MR was postprocedurally significantly reduced in both the DMR and FMR groups, whereas improvement of a decreased left ventricular ejection fraction was predominantly seen in the FMR group as compared with baseline. CONCLUSION Patients with severe, symptomatic aortic stenosis undergoing TAVI complicated by moderate or severe MR portend impaired prognosis. Particularly, patients with DMR are at increased risk for CV mortality during long-term follow-up.
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Kiramijyan S, Magalhaes MA, Koifman E, Didier R, Escarcega RO, Minha S, Baker NC, Negi SI, Torguson R, Gai J, Okubagzi P, Asch FM, Gaglia MA, Ben-Dor I, Satler LF, Pichard AD, Waksman R. Impact of baseline mitral regurgitation on short- and long-term outcomes following transcatheter aortic valve replacement. Am Heart J 2016; 178:19-27. [PMID: 27502848 DOI: 10.1016/j.ahj.2016.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 03/30/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The prevalence of concomitant significant mitral regurgitation (MR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) ranges from 2% to 33%. The impact of significant MR on post-TAVR outcomes remains controversial. METHODS The data from a cohort of patients with symptomatic severe AS undergoing TAVR at out institution were retrospectively analyzed. The last transthoracic echocardiogram (TTE) before the index TAVR procedure was selected as the baseline assessment of the degree of MR. The total study cohort (N = 589) was divided into 2 groups: significant ≥moderate MR (n = 68) versus nonsignificant <moderate MR (n = 521) at baseline. The 2 groups were compared in regard to baseline, imaging, procedural, and postprocedural characteristics. In-hospital, 30-day, and 1-year outcomes were assessed. Multivariate Cox regression survival analyses were performed to test the independent effect of ≥moderate MR on mortality at short- and long-term follow-up periods. RESULTS Patients with ≥moderate MR had a higher mortality rate versus patients with <moderate MR during the initial 30-day follow-up after TAVR (unadjusted log-rank P = .011, risk-adjusted P = .031, hazard ratio = 2.40, 95% CI 1.08-5.29). However, the mortality rates at 1-year follow-up postprocedure were similar between the 2 groups (unadjusted log-rank P = .553, risk-adjusted P = .331, hazard ratio = 0.70, 95% CI 0.35-1.43). Among the original ≥moderate group, 62.5% and 77.7% of patients had improved to <moderate MR at 30-day and 1-year follow-up, respectively. CONCLUSIONS Moderate or greater MR in patients undergoing TAVR is associated with a higher 30-day but not 1-year mortality. A majority of the patients demonstrated significant improvement in MR following TAVR.
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Zamorano J, Gonçalves A, Lancellotti P, Andersen KA, González-Gómez A, Monaghan M, Brochet E, Wunderlich N, Gafoor S, Gillam LD, La Canna G. The use of imaging in new transcatheter interventions: an EACVI review paper. Eur Heart J Cardiovasc Imaging 2016; 17:835-835af. [PMID: 27311822 DOI: 10.1093/ehjci/jew043] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 02/15/2016] [Indexed: 01/28/2023] Open
Abstract
Transcatheter therapies for the treatment of valve heart diseases have expanded dramatically over the last years. The new developments and improvements in devices and techniques, along with the increasing expertise of operators, have turned the catheter-based approaches for valvular disease into an established treatment option. Various imaging techniques are used during these procedures, but echocardiography plays an essential role during patient selection, intra-procedural monitoring, and post-procedure follow-up. The echocardiographic assessment of patients undergoing transcatheter interventions places demands on echocardiographers that differ from those of the routine evaluation of patients with valve disease, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of transcatheter valve therapies, this document intends to update the previous recommendations and address new advancements in imaging, particularly for those involved in any stage of the treatment of patients with valvular heart diseases.
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Papadopoulos N, El-Sayed Ahmad A, Thudt M, Fichtlscherer S, Meybohm P, Reyher C, Moritz A, Zierer A. Successful fast track protocol implementation for patients undergoing transapical transcatheter aortic valve implantation. J Cardiothorac Surg 2016; 11:55. [PMID: 27067581 PMCID: PMC4827191 DOI: 10.1186/s13019-016-0449-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/04/2016] [Indexed: 11/16/2022] Open
Abstract
Background The aim of the current study is to report our experience with fast-track treatment of patients undergoing transapical transcatheter aortic valve implantation (TA-TAVI) and to determine perioperative predictors for fast-track protocol failure. Methods Being one of the pioneering centers to start performing TA-TAVI back in 2005, we routinely included patients undergoing this procedure into our fast-track management program since 2008. Between January 2008 and June 2013, 207 consecutive high-risk patients (mean age 79 ± 7 years, mean Log. EuroSCORE 24 ± 10) who underwent TA-TAVI accordingly to our institutional fast-track approach were prospectively collected and analyzed. Uni- and multivariate analysis were performed to identify independent pre- and perioperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the intensive care unit (ICU) on the day of surgery or as readmission to the ICU 48 h after the initial discharge. Results Fast-track management was successful in 83 % of the patients. 30-day mortality was 8 %. Fast-track protocol failure (17 %) was associated with an outcome worsening compared to the remaining patients (mortality: 40 % vs. 2 % and mean hospital stay: 19 ± 12 vs. 10 ± 9 days; P = .002). Independent predictors of fast-track protocol failure were age ≥85 years (OR 3.1; CI 95 % 1.89–6.21), ejection fraction (EF) ≤30 % (OR 2.6; CI 95 % 1.99–7.52), moderate to severe preoperative mitral valve regurgitation (OR 2.7; CI 95 % 1.27–6.43) and fluoroscopy time ≥12 min (OR 2.9; CI 95 % 1.28–7.46). Conclusions Fast-track patient management following TA-TAVI is safe and reproducible in the majority of patients. Besides patient-related preoperative risk factors (age ≥85 years, EF ≤30 % and moderate to severe preoperative mitral valve regurgitation) a technically challenging intraoperative course as evidenced in a prolonged fluoroscopy time are independent predictors of fast-track protocol failure which is associated with high loss of patient outcome.
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Affiliation(s)
- Nestoras Papadopoulos
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany.
| | - Ali El-Sayed Ahmad
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Marlene Thudt
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Stephan Fichtlscherer
- Division of Cardiology, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt, Germany
| | - Patrick Meybohm
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Christian Reyher
- Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt/Main, Frankfurt, Germany
| | - Anton Moritz
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
| | - Andreas Zierer
- Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany
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Kiramijyan S, Koifman E, Asch FM, Magalhaes MA, Didier R, Escarcega RO, Negi SI, Baker NC, Jerusalem ZD, Gai J, Torguson R, Okubagzi P, Wang Z, Shults CC, Ben-Dor I, Corso PJ, Satler LF, Pichard AD, Waksman R. Impact of Functional Versus Organic Baseline Mitral Regurgitation on Short- and Long-Term Outcomes After Transcatheter Aortic Valve Replacement. Am J Cardiol 2016; 117:839-46. [PMID: 26873331 DOI: 10.1016/j.amjcard.2015.11.064] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022]
Abstract
The impact of the specific etiology of mitral regurgitation (MR) on outcomes in the transcatheter aortic valve replacement (TAVR) population is unknown. This study aimed to evaluate the longitudinal changes in functional versus organic MR after TAVR in addition to their impact on survival. Consecutive patients who underwent TAVR from May 2007 to May 2015 who had baseline significant (moderate or greater) MR were included. Transthoracic echocardiography was used to evaluate the cohort at baseline, post-procedure, 30-day, 6-month, and 1-year follow-up. The primary outcomes included mortality at 30 days and 1 year. Longitudinal, mixed-model regression analyses were performed to assess the differences in the magnitude of longitudinal changes of MR, left ventricular (LV) ejection fraction, and New York Heart Association functional class. Seventy patients (44% men, mean 83 years) with moderate or greater MR at baseline (30 functional vs 40 organic) were included, with the functional group having a statistically significant mean younger age and higher rates of previous coronary artery bypass grafting. Kaplan-Meier cumulative mortality rates were similar: 30 days (10% vs 17.5%, unadjusted log-ranked p = 0.413) and 1 year (29.4% vs 23.2%, unadjusted log-ranked p = 0.746) in the functional versus organic MR groups, respectively. There were greater degrees of short- and long-term improvement in MR severity (slope difference p = 0.0008), LV ejection fraction (slope difference p = 0.0009), and New York Heart Association class (slope difference p = 0.0054) in the functional versus organic group. In conclusion, patients with significant functional versus organic MR who underwent TAVR have similar short- and long-term survival; nevertheless, those with a functional origin are more likely to have significant improvements in MR severity, LV-positive remodeling, and functional class. These findings may help strategize therapies for MR in patients with combined aortic and mitral valve disease who are undergoing TAVR.
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O'Sullivan CJ, Tüller D, Zbinden R, Eberli FR. Impact of Mitral Regurgitation on Clinical Outcomes After Transcatheter Aortic Valve Implantation. Interv Cardiol 2016; 11:54-58. [PMID: 29588707 DOI: 10.15420/icr.2016:11:1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
| | - David Tüller
- Department of Cardiology, Triemli Hospital, Zurich, Switzerland
| | - Rainer Zbinden
- Department of Cardiology, Triemli Hospital, Zurich, Switzerland
| | - Franz R Eberli
- Department of Cardiology, Triemli Hospital, Zurich, Switzerland
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Costantino MF, Dores E, Innelli P, Matera A, Santillo V, Violini R, Fiorilli R, Cappabianca G, Marraudino N, Picano E, Tarsia G. The beneficial effects of TAVI in mitral insufficiency. Cardiovasc Ultrasound 2015; 13:49. [PMID: 26714887 PMCID: PMC4696344 DOI: 10.1186/s12947-015-0040-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 12/02/2015] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies have suggested that concomitant mitral regurgitation (MR) is a risk factor for acute transcatheter aortic valve implantation (TAVI) failure, but may improve afterwards. Aim of this study was to assess the prevalence, clinical meaning and modifications of MR in patients undergoing TAVI. Methods In a retrospective, two-center (Potenza-San Carlo and Roma- San Camillo) study, from January 2010 to June 2014 we enrolled 165 consecutive patients (age =80 ± 5 years, 74 males, Ejection Fraction 51 ± 9 %) referred for TAVI with either Medtronic Core-ReValving System (in 114 patients, 69 %) or balloon-expandable Edwards SAPIEN/SAPIEN XT (in 51 patients, 31 %). All patients underwent TTE and TEE assessment of MR (from 1, mild to 4 = severe according to ESC latest guidelines) with core lab reading by a single observer blinded to patient identity and status. Assessment was performed at baseline (24 h prior to intervention) and at 1, 6, 12 and 24 months. Results Mild-to-Moderate MR (grade 1–2) was present in 137 patients and Moderate-to-Severe MR (grade 3–4) was present in 28 patients. No significant differences were seen comparing perioperative mortality and morbidity between the two groups. In the group of preoperative MR grade 3–4 the mean decrease from MR pre-TAVI to MR at 1 month post-TAVI was 0.464 (p < 0.0001) and this improvement was persistent at 6 months (p < 0.0001) and at 12 months (p < 0.0001), with partial benefit loss at 1 and 2 years. The mean difference from Left Atrial volume post-TAVI at 1 month was 16.5 ml (p < 0.0001) and this improvement was persistent at 12 months 12.12 ml (p < 0.0001). Conclusions TAVI effectively treats the aortic valve but as a beneficial by product also ameliorates concomitant MR. The presence of moderate-to-severe MR does not increase the acute risk of failure of TAVI. In successful procedures, the MR improves immediately and persistently.
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Affiliation(s)
- Marco Fabio Costantino
- Cardiology Intensive Care Unit "Alta Specialità del Cuore" Department AORN San Carlo Hospital Potenza, Via Potito Petrone, 85100, Potenza, Italy.
| | - Ernesta Dores
- UO Emergency Care, San Giovanni di Dio Hospital Melfi -ASP, Potenza, Italy
| | - Pasquale Innelli
- UO Cardiology Intensive Care Unit, Villa d'Agri Hospital -ASP, Potenza, Italy
| | - Antonella Matera
- Cardiology Intensive Care Unit "Alta Specialità del Cuore" Department AORN San Carlo Hospital Potenza, Via Potito Petrone, 85100, Potenza, Italy
| | - Vincenza Santillo
- Cardiology Intensive Care Unit "Alta Specialità del Cuore" Department AORN San Carlo Hospital Potenza, Via Potito Petrone, 85100, Potenza, Italy
| | - Roberto Violini
- UO Interventional Cardiology Unit, S. Camillo Forlanini Hospital, Rome, Italy
| | - Rosario Fiorilli
- UO Interventional Cardiology Unit, S. Camillo Forlanini Hospital, Rome, Italy
| | | | | | | | - Giandomenico Tarsia
- Cardiology Intensive Care Unit "Alta Specialità del Cuore" Department AORN San Carlo Hospital Potenza, Via Potito Petrone, 85100, Potenza, Italy
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Rougé A, Huttin O, Aslam R, Vaugrenard T, Jouve T, Angioi M, Maureira P. Mid-term results of 150 TAVI comparing apical versus femoral approaches. J Cardiothorac Surg 2015; 10:147. [PMID: 26530142 PMCID: PMC4632837 DOI: 10.1186/s13019-015-0360-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/28/2015] [Indexed: 11/10/2022] Open
Abstract
Background Transcatheter aortic-valve implantation (TAVI) is a new therapeutic choice for treating aortic stenosis in patients considered high risk for surgery. This blooming therapeutic technique still requires evaluation of medium and long term outcome. Method We hereby report our results of the first 150 consecutive patients to receive TAVI implants in our population recruited from July 2009 to March 2013 in a retrospective and monocentric study. We analyzed long term morbidity and mortality criteria. We compared the apical and femoral approach results and researched predictors of cardiac mortality. Results The mean monitoring period was 387.62 days, mean Euroscore was 21.8, and mean Society of Thoracic Surgeons (STS) risk score was 9.2. The success rate for the procedure was 94.6 %. A total of 39 patients died. The mortality rates at the immediate perioperative point, 30 days, 1 year, and 2 years, were 4 %, 11.3 %, 22.7 %, and 26 %, respectively. As regards complications, there were 10 hemodynamic complications (6.6 %) and 20 vascular (13.3 %), 11 cardiac tamponades (7.4 %), eight mechanical (5.3 %), ten major hemorrhagic (6.7 %), 14 pulmonary (9.3 %), and 18 infectious complications (12 %). When comparing the rates of reported complications in terms of different approaches, we observed significantly more hemodynamic complications in the apical group (p = 0.049). Pulmonary complications were also significantly more common in cases of apical approach (p = 0.029). The majority of the patients reported clear functional improvement throughout their follow-up. Conclusion The results of the first 150 patients to receive the implant at the Nancy University Teaching Hospital (CHU Nancy) were consistent with findings in the literature. TAVI proved a credible and effective alternative to surgical valve replacement for patients at high risk during surgery.
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Affiliation(s)
- Alain Rougé
- Service de Cardiologie, CHU de Nancy, Hôpital Brabois, rue du Morvan, F-54511, Vandoeuvre-les-Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Olivier Huttin
- Service de Cardiologie, CHU de Nancy, Hôpital Brabois, rue du Morvan, F-54511, Vandoeuvre-les-Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Rumas Aslam
- Service de Cardiologie, CHU de Nancy, Hôpital Brabois, rue du Morvan, F-54511, Vandoeuvre-les-Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Thibaud Vaugrenard
- Service de Cardiologie, CHU de Nancy, Hôpital Brabois, rue du Morvan, F-54511, Vandoeuvre-les-Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Thomas Jouve
- Service de Néphrologie - CHU Grenoble, Boulevard de la Chantourne, Grenoble, France.
| | - Michael Angioi
- Service de Cardiologie, CHU de Nancy, Hôpital Brabois, rue du Morvan, F-54511, Vandoeuvre-les-Nancy, France. .,Université de Lorraine, Nancy, France.
| | - Pablo Maureira
- Service de Chirurgie Cardiaque, CHU de Nancy, Hôpital Brabois, rue du Morvan, F-54511, Vandoeuvre-les-Nancy, France. .,Université de Lorraine, Nancy, France.
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O'Sullivan CJ, Stortecky S, Bütikofer A, Heg D, Zanchin T, Huber C, Pilgrim T, Praz F, Buellesfeld L, Khattab AA, Blöchlinger S, Carrel T, Meier B, Zbinden S, Wenaweser P, Windecker S. Impact of mitral regurgitation on clinical outcomes of patients with low-ejection fraction, low-gradient severe aortic stenosis undergoing transcatheter aortic valve implantation. Circ Cardiovasc Interv 2015; 8:e001895. [PMID: 25657315 DOI: 10.1161/circinterventions.114.001895] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Up to 1 in 6 patients undergoing transcatheter aortic valve implantation (TAVI) present with low-ejection fraction, low-gradient (LEF-LG) severe aortic stenosis and concomitant relevant mitral regurgitation (MR) is present in 30% to 55% of these patients. The effect of MR on clinical outcomes of LEF-LG patients undergoing TAVI is unknown. METHODS AND RESULTS Of 606 consecutive patients undergoing TAVI, 113 (18.7%) patients with LEF-LG severe aortic stenosis (mean gradient ≤40 mm Hg, aortic valve area <1.0 cm(2), left ventricular ejection fraction <50%) were analyzed. LEF-LG patients were dichotomized into ≤mild MR (n=52) and ≥moderate MR (n=61). Primary end point was all-cause mortality at 1 year. No differences in mortality were observed at 30 days (P=0.76). At 1 year, LEF-LG patients with ≥moderate MR had an adjusted 3-fold higher rate of all-cause mortality (11.5% versus 38.1%; adjusted hazard ratio, 3.27 [95% confidence interval, 1.31-8.15]; P=0.011), as compared with LEF-LG patients with ≤mild MR. Mortality was mainly driven by cardiac death (adjusted hazard ratio, 4.62; P=0.005). As compared with LEF-LG patients with ≥moderate MR assigned to medical therapy, LEF-LG patients with ≥moderate MR undergoing TAVI had significantly lower all-cause mortality (hazard ratio, 0.38; 95% confidence interval, 0.019-0.75) at 1 year. CONCLUSIONS Moderate or severe MR is a strong independent predictor of late mortality in LEF-LG patients undergoing TAVI. However, LEF-LG patients assigned to medical therapy have a dismal prognosis independent of MR severity suggesting that TAVI should not be withheld from symptomatic patients with LEF-LG severe aortic stenosis even in the presence of moderate or severe MR.
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Affiliation(s)
- Crochan J O'Sullivan
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Stefan Stortecky
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Anne Bütikofer
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Dik Heg
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Thomas Zanchin
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Christoph Huber
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Thomas Pilgrim
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Fabien Praz
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Lutz Buellesfeld
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Ahmed A Khattab
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Stefan Blöchlinger
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Thierry Carrel
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Bernhard Meier
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Stephan Zbinden
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Peter Wenaweser
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.)
| | - Stephan Windecker
- From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
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Itabashi Y, Shibayama K, Mihara H, Utsunomiya H, Berdejo J, Arsanjani R, Siegel R, Chakravarty T, Jilaihawi H, Makkar RR, Shiota T. Significant Reduction in Mitral Regurgitation Volume Is the Main Contributor for Increase in Systolic Forward Flow in Patients with Functional Mitral Regurgitation after Transcatheter Aortic Valve Replacement: Hemodynamic Analysis Using Echocardiography. Echocardiography 2015; 32:1621-7. [PMID: 25817306 DOI: 10.1111/echo.12936] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Reduction in mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR) has previously been reported. However, the hemodynamic effects of TAVR in patients with MR have not been previously evaluated. METHODS We analyzed 571 patients who underwent TAVR from December 2010 to December 2013. We studied 20 patients with moderate or severe preprocedural functional mitral regurgitation (FMR) who also had a follow-up transthoracic echocardiography (TTE) examination between 90 and 360 days (median 213 days) after TAVR (Significant FMR Group). We also studied age- and gender-matched 20 patients with mild or lesser MR (Nonsignificant MR Group). Left ventricular functional measurements were assessed using echocardiography before and after TAVR. Left ventricular outflow tract stroke volume measurements using pulsed-wave Doppler (SVLVOT ) were calculated as a representative of systolic forward flow, and stroke volume by the Simpson's method (SVSimpson ) was calculated as a parameter of degree of LV contraction. RESULTS MR grade improved in 22 of 40 patients after TAVR. In both groups, BNP level decreased, left ventricular ejection fraction increased, and SVLVOT increased after TAVR. SVSimpson increased in the Nonsignificant MR Group and remained unchanged in the Significant FMR Group. Vena contracta width of MR (MRVC) decreased in the Significant FMR Group. Using multivariable analysis in the Significant FMR Group, the increase in SVLVOT significantly correlated with the decrease in MRVC (P < 0.05). CONCLUSIONS SVLVOT increased significantly after TAVR in patients with FMR. In these patients, increase in SVLVOT after TAVR was associated with decrease in severity of MR.
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Affiliation(s)
- Yuji Itabashi
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Kentaro Shibayama
- Heart Center, Tokyo Bay Urayasu/Ichikawa Medical Center, Chiba, Japan
| | - Hirotsugu Mihara
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Hiroto Utsunomiya
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Javier Berdejo
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Reza Arsanjani
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Robert Siegel
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Tarun Chakravarty
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Hasan Jilaihawi
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Raj R Makkar
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Takahiro Shiota
- Noninvasive Cardiac Laboratory, Cedars-Sinai Heart Institute, Los Angeles, California
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Meta-analysis of mortality outcomes and mitral regurgitation evolution in 4,839 patients having transcatheter aortic valve implantation for severe aortic stenosis. Am J Cardiol 2014; 114:875-82. [PMID: 25092192 DOI: 10.1016/j.amjcard.2014.06.022] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 06/25/2014] [Accepted: 06/25/2014] [Indexed: 11/20/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is an effective alternative therapy in selected patients with severe aortic stenosis. The role and effects of coexistent moderate to severe mitral regurgitation (msMR) in patients who undergo TAVI remain unclear. Thirteen studies enrolling 4,839 patients who underwent TAVI, including patients with msMR, were considered in a meta-analysis and analyzed for all-cause-mortality; a further meta-analysis was performed to assess mitral regurgitation (MR) evolution after TAVI. In patients with msMR, all-cause-mortality after TAVI was significantly increased at 30-day (effect size [ES] -0.18, 95% confidence interval [CI] -0.31 to -0.04, I(2) = 46.51, Q = 7.48), 1-year (ES -0.22, 95% CI -0.36 to -0.08, I(2) = 56.20, Q = 11.41), and 2-year (ES -0.15, 95% CI -0.27 to -0.02, I(2) = 0.00, Q = 2.64) follow-up compared with patients with absent or mild MR, independent of baseline left ventricular ejection fraction. Interestingly, the impact of msMR on outcomes was statistically stronger when the CoreValve system was used. TAVI was also associated with an improvement in MR entity at 3- and 6-month follow-up (overall ES -0.19, 95% CI -0.37 to -0.01, I(2) = 61.52, Q = 10.39). In conclusion, the presence of preoperative msMR in patients with severe, symptomatic aortic stenosis who undergo TAVI negatively affects outcomes after TAVI. In addition, in the same group of patients, a trend toward a reduction in MR severity was observed. Whether the decrease in MR severity affects mortality after TAVI remains to be defined.
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Khawaja MZ, Williams R, Hung J, Arri S, Asrress KN, Bolter K, Wilson K, Young CP, Bapat V, Hancock J, Thomas M, Redwood S. Impact of preprocedural mitral regurgitation upon mortality after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. Heart 2014; 100:1799-803. [PMID: 25155800 PMCID: PMC4215343 DOI: 10.1136/heartjnl-2014-305775] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To identify the effects of preprocedural significant mitral regurgitation (MR) and change in MR severity upon mortality after transcatheter aortic valve implantation (TAVI) using the Edwards SAPIEN system. Methods A retrospective analysis of 316 consecutive patients undergoing TAVI for aortic stenosis at a single centre in the UK between March 2008 and January 2013. Patients were stratified into two groups according to severity of MR: ≥grade 3 were classed as significant and ≤grade 2 were non-significant. Change in MR severity was assessed by comparison of baseline and 30-day echocardiograms. Results 60 patients had significant MR prior to TAVI (19.0%). These patients were of higher perioperative risk (logistic EuroScore 28.7±16.6% vs 20.3±10.7%, p=0.004) and were more dyspnoeic (New York Heart Association class IV 20.0% vs 7.4%, p=0.014). Patients with significant preprocedural MR displayed greater 12-month and cumulative mortality (28.3% vs 20.2%, log-rank p=0.024). Significant MR was independently associated with mortality (HR 4.94 (95% CI 2.07 to 11.8), p<0.001). Of the 60 patients with significant MR only 47.1% had grade 3–4 MR at 30 days (p<0.001). Patients in whom MR improved had lower mortality than those in whom it deteriorated (log-rank p=0.05). Conclusions Significant MR is frequently seen in patients undergoing TAVI and is independently associated with increased all-cause mortality. Yet almost half also exhibit significant improvements in MR severity. Those who improve have better outcomes, and future work could focus upon identifying factors independently associated with such an improvement.
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Affiliation(s)
- M Z Khawaja
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - R Williams
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - J Hung
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK
| | - S Arri
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - K N Asrress
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - K Bolter
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - K Wilson
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - C P Young
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - V Bapat
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - J Hancock
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - M Thomas
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - S Redwood
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
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Bax JJ, Delgado V, Bapat V, Baumgartner H, Collet JP, Erbel R, Hamm C, Kappetein AP, Leipsic J, Leon MB, MacCarthy P, Piazza N, Pibarot P, Roberts WC, Rodés-Cabau J, Serruys PW, Thomas M, Vahanian A, Webb J, Zamorano JL, Windecker S. Open issues in transcatheter aortic valve implantation. Part 1: patient selection and treatment strategy for transcatheter aortic valve implantation. Eur Heart J 2014; 35:2627-38. [PMID: 25062952 DOI: 10.1093/eurheartj/ehu256] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
An exponential increase in the use of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis has been witnessed over the recent years. The current article reviews different areas of uncertainty related to patient selection. The use and limitations of risk scores are addressed, followed by an extensive discussion on the value of three-dimensional imaging for prosthesis sizing and the assessment of complex valve anatomy such as degenerated bicuspid valves. The uncertainty about valvular stenosis severity in patients with a mismatch between the transvalvular gradient and the aortic valve area, and how integrated use of echocardiography and computed tomographic imaging may help, is also addressed. Finally, patients referred for TAVI may have concomitant mitral regurgitation and/or coronary artery disease and the management of these patients is discussed.
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Affiliation(s)
- Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2 2300 RC, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2 2300 RC, Leiden, The Netherlands
| | - Vinayak Bapat
- Department of Cardiology and Cardiothoracic Surgery, St Thomas' Hospital, London, UK
| | - Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Jean P Collet
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Raimund Erbel
- Department of Cardiology, West-German Heart Center Essen, University Duisburg Essen, Essen, Germany
| | - Christian Hamm
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | | | - Jonathon Leipsic
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Martin B Leon
- Columbia University Medical Center, Center for Interventional Vascular Therapy, New York Presbyterian Hospital, New York, USA
| | | | - Nicolo Piazza
- Interventional Cardiology, McGill University Health Center, Montreal, Canada Cardiovascular Surgery, German Heart Center Munich, Bavaria, Germany
| | | | - William C Roberts
- Baylor Heart and Vascular Institute and the Departments of Internal Medicine (Division of Cardiology) and Pathology, Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Martyn Thomas
- Department of Cardiology and Cardiothoracic Surgery, St Thomas' Hospital, London, UK
| | - Alec Vahanian
- Bichat Hospital, University Paris VII, Paris, France
| | - John Webb
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jose Luis Zamorano
- Cardiac Imaging Department, University Hospital Ramon y Cajal, Madrid, Spain
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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Barbanti M, Dvir D, Tan J, Webb JG. Aortic stenosis and mitral regurgitation: implications for transcatheter valve treatment. EUROINTERVENTION 2014; 9 Suppl:S69-71. [PMID: 24025961 DOI: 10.4244/eijv9ssa13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Marco Barbanti
- St. Paul's Hospital, University of British Columbia, Vancouver, Canada
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Nombela-Franco L, Ribeiro HB, Urena M, Allende R, Amat-Santos I, DeLarochellière R, Dumont E, Doyle D, DeLarochellière H, Laflamme J, Laflamme L, García E, Macaya C, Jiménez-Quevedo P, Côté M, Bergeron S, Beaudoin J, Pibarot P, Rodés-Cabau J. 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. J Am Coll Cardiol 2014; 63:2643-58. [PMID: 24681140 DOI: 10.1016/j.jacc.2014.02.573] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 02/18/2014] [Accepted: 02/25/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Luis Nombela-Franco
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada; Cardiovascular Institute, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | | | - Marina Urena
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
| | | | | | | | - Eric Dumont
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
| | - Daniel Doyle
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
| | | | | | - Louis Laflamme
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
| | - Eulogio García
- Cardiovascular Institute, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Carlos Macaya
- Cardiovascular Institute, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Pilar Jiménez-Quevedo
- Cardiovascular Institute, Hospital Clínico San Carlos, Universidad Complutense, Madrid, Spain
| | - Mélanie Côté
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
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Abstract
Transcatheter aortic valve replacement emerged ≈20 years ago and changed the landscape of structural interventional cardiology. The first experiments in animal models provided proofs of the concept and the substrate for the first percutaneous valve implantation in patients. The initial promising results in a clinical setting drew the attention of the industry and of the scientific community, and an effort was made for the past 12 years to address the limitations of the technology, facilitate the procedure, minimize the risk of complications, and broaden the applications of transcatheter aortic valve replacement. This article reviews the evolution of transcatheter aortic valve replacement, presents the first steps in this field, cites the evidence from registries and clinical trials, highlights the limitations of this treatment, and discusses the future perspectives and the developments proposed to address the current pitfalls.
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Affiliation(s)
- Christos V. Bourantas
- From the Department of Interventional Cardiology, ThoraxCenter, Erasmus Medical Center, Rotterdam, The Netherlands (C.V.B., P.W.S.); and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom (P.W.S.)
| | - Patrick W. Serruys
- From the Department of Interventional Cardiology, ThoraxCenter, Erasmus Medical Center, Rotterdam, The Netherlands (C.V.B., P.W.S.); and International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom (P.W.S.)
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Wilbring M, Tugtekin SM, Ritzmann M, Arzt S, Schmidt T, Matschke K, Kappert U, Alexiou K. Transcatheter aortic valve implantation reduces grade of concomitant mitral and tricuspid valve regurgitation and pulmonary hypertension. Eur J Cardiothorac Surg 2014; 46:818-24. [PMID: 24574441 DOI: 10.1093/ejcts/ezu037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The presence of concomitant mitral (MR) or tricuspid regurgitation (TR) is a common issue in patients undergoing transcatheter aortic valve implantation (TAVI). The objective was (i) to analyse the outcomes of patients with concomitant moderate or more severe MR, (ii) to compare the outcomes with those of TAVI patients without concomitant MR and (iii) to evaluate the impact of TAVI on grade of concomitant MR. METHODS For creating a homogeneous study group, the study was restricted to transapical (TA)-TAVI patients. Since 2008, 615 patients have undergone TAVI at our institution, 386 of these using the TA approach with the Edwards SAPIEN™ bioprosthesis. Out of these, 116 (30.1%) presented with concomitant moderate or more severe MR. Mean logistic European System for Cardiac Operative Risk (EuroSCORE) was 18.1 ± 11.5%, EuroSCORE II 5.4 ± 0.7%. Intra- and post-hospital course, change in grade of MR, TR, right ventricular systolic pressure (RVSP) and tricuspid annular plane systolic excursion (TAPSE) were particularly analysed. Outcomes were compared with those of the remaining TA-TAVI patients (n = 270). Mean follow-up time was 471 ± 391 days, giving a total of 135 patient-years. RESULTS Three patients (2.6%) died during primary hospital stay. Estimated 1-, 2-, 3- and 4-year survival rates were 76.7, 75.6, 68.3 and 50.6% for study and 78.1, 77.8, 61.1 and 55.0% for control groups, respectively. Postoperative morbidity and mortality did not differ significantly from those of the control group. Postoperatively, a significant reduction in MR (2.1 ± 0.2 to 1.5 ± 0.7; P < 0.01) and TR (1.9 ± 0.5 to 1.5 ± 0.7; P < 0.01) was observed. Likewise, RVSP decreased significantly from 46 ± 16 to 39 ± 15 mmHg (P < 0.01) and TAPSE non-significantly (21.9 ± 7.3 to 19.5 ± 5.5 mm; P = 0.07). After 3-6 months, 68.9% of the patients were at New York Heart Association (NYHA) Class I or II, 25% at Class III and 6.0% downgraded to Class IV. A reason for remaining in NYHA Class III or downgrading to NYHA Class IV could not be detected, and particularly, there was no impact of grade of MR/TR, left ventricular ejection fraction, TAPSE or right ventricular endsystolic pressure (RVESP) on outcomes or NYHA class. CONCLUSION TA-TAVI in patients with concomitant moderate or more severe MR provides results comparable with those of TA-TAVI in general. Concomitant MR had no significant impact on the short- and mid-term outcomes. A significant reduction in MR, TR and pulmonary hypertension was observed after TA-TAVI during short-term follow-up. Nonetheless, a relevant number of patients did not experience an improvement in NYHA class.
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Affiliation(s)
- Manuel Wilbring
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Sems-Malte Tugtekin
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Mike Ritzmann
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Sebastian Arzt
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Torsten Schmidt
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Konstantin Alexiou
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
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Kim CA, Rasania SP, Afilalo J, Popma JJ, Lipsitz LA, Kim DH. Functional status and quality of life after transcatheter aortic valve replacement: a systematic review. Ann Intern Med 2014; 160:243-54. [PMID: 24727842 PMCID: PMC4039034 DOI: 10.7326/m13-1316] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The functional and quality-of-life benefits of transcatheter aortic valve replacement (TAVR) have not been established. PURPOSE To evaluate the changes in functional status and quality of life after TAVR. DATA SOURCES MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1 January 2002 to 30 September 2013. STUDY SELECTION Studies of TAVR that reported the New York Heart Association (NYHA) class, Short Form-12/36 Health Survey physical and mental component summary (points), or other measures of functional status. DATA EXTRACTION Two reviewers independently extracted the mean change (follow-up minus baseline) in primary outcomes. Because of substantial heterogeneity, data were not pooled; the range of mean change was summarized. DATA SYNTHESIS We identified 60 observational studies (56 pre–post comparison and 4 head-to-head comparative studies) and 2 randomized, controlled trials (11 205 patients). Most studies showed a clinically important decrease in NYHA class at 6 to 11 months (range, -0.8 to -2.1 classes) and 12 to 23 months (range, -0.8 to -2.1 classes). The improvement in the Short Form-12/36 Health Survey physical component score was clinically important over 12 months (range, 4.9 to 26.9 points), and the change in mental component score was smaller (range, 1.0 to 8.9 points).Clinically important improvements were seen in other disease-specific measures but were less consistently seen in general health measures. LIMITATIONS Comparative evidence is limited by few head-to-head studies. Survivor bias may have overestimated the benefits. CONCLUSION Transcatheter aortic valve replacement provides clinically important benefits in physical function and disease-specific measures of quality of life but modest benefits in psychological and general health measures. More comparative studies on functional status and quality of life are needed for informed treatment decision making.
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Affiliation(s)
- Caroline A. Kim
- From Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Jewish General Hospital and McGill University, Montreal, Quebec, Canada; and Geisinger Medical Center, Danville, Pennsylvania
| | - Suraj P. Rasania
- From Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Jewish General Hospital and McGill University, Montreal, Quebec, Canada; and Geisinger Medical Center, Danville, Pennsylvania
| | - Jonathan Afilalo
- From Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Jewish General Hospital and McGill University, Montreal, Quebec, Canada; and Geisinger Medical Center, Danville, Pennsylvania
| | - Jeffrey J. Popma
- From Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Jewish General Hospital and McGill University, Montreal, Quebec, Canada; and Geisinger Medical Center, Danville, Pennsylvania
| | - Lewis A. Lipsitz
- From Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Jewish General Hospital and McGill University, Montreal, Quebec, Canada; and Geisinger Medical Center, Danville, Pennsylvania
| | - Dae Hyun Kim
- From Beth Israel Deaconess Medical Center, Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Jewish General Hospital and McGill University, Montreal, Quebec, Canada; and Geisinger Medical Center, Danville, Pennsylvania
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Barbanti M, Webb JG, Hahn RT, Feldman T, Boone RH, Smith CR, Kodali S, Zajarias A, Thompson CR, Green P, Babaliaros V, Makkar RR, Szeto WY, Douglas PS, McAndrew T, Hueter I, Miller DC, Leon MB. Impact of Preoperative Moderate/Severe Mitral Regurgitation on 2-Year Outcome After Transcatheter and Surgical Aortic Valve Replacement. Circulation 2013; 128:2776-84. [DOI: 10.1161/circulationaha.113.003885] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The effect of preoperative mitral regurgitation (MR) on clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) is controversial. This study sought to examine the impact of moderate and severe MR on outcomes after TAVR and surgical aortic valve replacement (SAVR).
Methods and Results—
Data were drawn from the randomized Placement of Aortic Transcatheter Valve (PARTNER) Trial cohort A patients with severe, symptomatic aortic stenosis undergoing either TAVR (n=331) or SAVR (n=299). Both TAVR and SAVR patients were dichotomized according to the degree of preoperative MR (moderate/severe versus none/mild). At baseline, moderate or severe MR was reported in 65 TAVR patients (19.6%) and 63 SAVR patients (21.2%). At 30 days, among survivors who had isolated SAVR/TAVR, moderate/severe MR had improved in 25 SAVR patients (69.4%) and 30 TAVR patients (57.7%), was unchanged in 10 SAVR patients (27.8%) and 19 TAVR patients (36.5%), and worsened in 1 SAVR patient (2.8%) and 4 TAVR patients (5.8%; all
P
=NS). Mortality at 2 years was higher in SAVR patients with moderate or severe MR than in those with mild or less MR (49.8% versus 28.1%; adjusted hazard ratio, 1.73; 95% confidence interval, 1.01–2.96;
P
=0.04). In contrast, MR severity at baseline did not affect mortality in TAVR patients (37.0% versus 32.7%, moderate/severe versus none/mild; hazard ratio, 1.14; 95% confidence interval, 0.72–1.78;
P
=0.58;
P
for interaction=0.05).
Conclusions—
Both TAVR and SAVR were associated with a significant early improvement in MR in survivors. However, moderate or severe MR at baseline was associated with increased 2-year mortality after SAVR but not after TAVR. TAVR may be a reasonable option in selected patients with combined aortic and mitral valve disease.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00530894.
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Warraich HJ, Matyal R, Bergman R, Hess PE, Khabbaz K, Manning WJ, Mahmood F. Impact of aortic valve replacement for aortic stenosis on dynamic mitral annular motion and geometry. Am J Cardiol 2013; 112:1445-9. [PMID: 23891429 DOI: 10.1016/j.amjcard.2013.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/04/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
Abstract
The impact of aortic valve replacement (AVR) on the dynamic geometry and motion of the mitral annulus remains unknown. We analyzed the effects of AVR on the dynamic geometry and motion of the mitral annulus. We used 3-dimensional transesophageal echocardiography to analyze 39 consecutive patients undergoing elective surgical AVR for aortic stenosis. Intraoperative 3-dimensional transesophageal echocardiography was performed immediately before and after AVR. Volumetric data sets were analyzed using a software package capable of dynamically tracking the mitral annulus and leaflets during the entire systolic ejection phase. After AVR, there were significant decreases (p <0.01) in annular dimensions such as anteroposterior (3.5 ± 0.1 vs 3.2 ± 0.1 cm), anterolateral-posteromedial (3.7 ± 0.1 vs 3.5 ± 0.1 cm), and commissural diameters (3.7 ± 0.1 vs 3.3 ± 0.1 cm), as well as annular circumference (12.0 ± 0.30 vs 11.1 ± 0.2 cm) and 3-dimensional mitral annular area (mean 10.9 ± 0.6 vs 9.3 ± 0.3 cm(3)). Vertical mitral annular displacement was also reduced (6.2 ± 3.1 vs 4.3 ± 2.2 mm). Mitral annular nonplanarity angle (154 ± 1.5° vs 161 ± 1.6°) and aorto-mitral angle (133 ± 3.3° vs 142 ± 2.0°) were both increased after AVR, suggesting reduced nonplanar shape of the mitral annulus and reduced aorto-mitral flexion. In conclusion, these data demonstrate that mitral annular size is reduced immediately after AVR and that the dynamic motion of the mitral annulus is restricted. These findings may have important clinical implications for patients undergoing AVR with concurrent mitral regurgitation.
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Gonçalves A, Solomon SD. Mitral regurgitation in transcatheter aortic valve replacement: the complexity of multivalvular disease. Circulation 2013; 128:2101-3. [PMID: 24088529 DOI: 10.1161/circulationaha.113.006196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tsang W, Meineri M, Hahn RT, Veronesi F, Shah AP, Osten M, Nathan S, Russo M, Lang RM, Horlick EM. A three-dimensional echocardiographic study on aortic-mitral coupling in transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2013; 14:950-6. [PMID: 23720379 DOI: 10.1093/ehjci/jet058] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Normal aortic valve (AV) and mitral valve (MV) function in a reciprocal interdependent fashion. We hypothesized that MV function would be affected by severe aortic stenosis (AS) and that it would remain altered after transcatheter AV replacement (TAVR). Using three-dimensional (3D) echocardiography, we studied aortic-mitral coupling in patients with severe AS undergoing TAVR and compared them with controls. METHODS AND RESULTS Three-dimensional transoesophageal echocardiography (Philips iE33) was performed on 43 patients: 27 with severe AS studied pre- and post-TAVR and 16 controls. A custom software tracked the aortic annulus (AoA) and mitral annulus (MA), allowing dynamic automated measurements of AoA and MA morphology, angle, and motion. The AS pre-TAVR patients had significantly reduced MA displacement, MA area, and maximum AoA area compared with the controls. Post-TAVR, MA displacement, MA area, and AoA area remained reduced. End-systolic AoA-MA angle was significantly wider in the AS patients compared with the controls and remained wider post-TAVR. Pre-TAVR, there was no difference in MA or AoA dynamics between patients with mild vs. moderate-to-severe MA calcium; Edwards-Sapien vs. a Medtronic CoreValve valve; normal vs. reduced left ventricular systolic function whereas post-TAVR, MA dynamics were significantly reduced in those with moderate-to-severe MA calcium. CONCLUSION This is the first study to demonstrate that AS can affect a secondary 'unaffected' valve, the MV, due to the calcification in the aortic-mitral fibrous continuity. TAVR does not result in recovery of MV structure. These changes have implications in the future TAVR valve development and the possible need for MV assessment pre- and post-TAVR.
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Affiliation(s)
- Wendy Tsang
- University of Chicago Medical Center, 5841 South Maryland Avenue, MC 5084, Chicago, IL 60637, USA
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Kische S, D'Ancona G, Paranskaya L, Schubert J, Arsoy N, Hauenstein KH, Alozie A, Jovanovich B, Nienaber C, Ince H. Staged total percutaneous treatment of aortic valve pathology and mitral regurgitation: institutional experience. Catheter Cardiovasc Interv 2013; 82:E552-63. [PMID: 23359543 DOI: 10.1002/ccd.24809] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 12/05/2012] [Accepted: 01/01/2013] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Stephan Kische
- Medical Faculty, Department of Cardiology at University Hospital Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
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