Impact of TAVI on Mitral Regurgitation: A Prospective Echocardiographic Study

Mechanisms and implications of mitral regurgitation in patients with severe aortic stenosis who received transcatheter aortic valve replacement

INTRODUCTION

This study aimed to investigate the mechanisms and clinical implications of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) who received transcatheter aortic valve replacement (TAVR).

METHODS

We conducted retrospective echocardiographic analyses at baseline and 6 months after TAVR in 140 patients with symptomatic AS (85 ± 5 years) who underwent TAVR. We defined significant MR as ≥ moderate based on evaluation of transthoracic echocardiography (TTE).

RESULTS

There were 48 patients (34%) with preexisting MR at the baseline. Among measured TTE parameters, end-systolic wall stress (ESWS), mitral annulus area, and mitral valve thickening index were independent factors associated with preexisting MR (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.005-1.021; OR: 1.740, 95% CI: 1.314-2.376; OR: 2.306, 95% CI: 1.426-3.848; respectively). Six months after TAVR, there were 34 patients with post-existing MR, A history of atrial fibrillation and ESWS after TAVR were independent factors (OR: 3.013, 95% CI: 1.208-7.556; OR: 1.013, 95% CI: 1.000-1.023; respectively). The Kaplan-Meier plot indicated that preexisting MR was a risk factor for heart failure-related events within 1 year of discharge after TAVR (p = .012).

CONCLUSIONS

In patients who underwent TAVR for severe AS, preexisting MR was associated with having a thickened mitral valve and large mitral annulus size induced by high ESWS. These patients may have worse prognosis after TAVR and should be closely monitored in the long term.

Mitral valve transcatheter edge-to-edge repair

Mitral regurgitation (MR) is the most prevalent valvular heart disease and, when left untreated, results in reduced quality of life, heart failure, and increased mortality. Mitral valve transcatheter edge-to-edge repair (M-TEER) has matured considerably as a non-surgical treatment option since its commercial introduction in Europe in 2008. As a result of major device and interventional improvements, as well as the accumulation of experience by the interventional cardiologists, M-TEER has emerged as an important therapeutic strategy for patients with severe and symptomatic MR in the current European and American guidelines. Herein, we provide a comprehensive up-do-date overview of M-TEER. We define preprocedural patient evaluation and highlight key aspects for decision-making. We describe the currently available M-TEER systems and summarise the evidence for M-TEER in both primary mitral regurgitation (PMR) and secondary mitral regurgitation (SMR). In addition, we provide recommendations for device selection, intraprocedural imaging and guiding, M-TEER optimisation and management of recurrent MR. Finally, we provide information on major unsolved questions and "grey areas" in M-TEER.

Impact of Transcatheter Aortic Valve Implantation Among Patients With Co-existing Mild to Moderate Mitral Regurgitation

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.

Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation

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.

Relationship between Mitral Regurgitation and Transcatheter Aortic Valve Implantation: a Multi-Institutional Follow-up Study

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.

Predictors of Mitral Regurgitation Severity Improvement in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

Background

Mitral regurgitation (MR) is frequently associated with severe aortic stenosis (AS). Significant MR is associated with less favorable prognosis after transcatheter aortic valve implantation (TAVI), including higher early and late mortality rate. The severity of MR is improved in about half of patients undergoing TAVI. However, the predictors of MR improvement after TAVI are unknown. We sought to investigate whether several demographic, clinical, echocardiographic and laboratory parameters and procedure characteristics are predictive of MR severity improvement after TAVI procedure.

Methods

A total of 309 consecutive patients with severe symptomatic AS underwent TAVI procedure in our center from July 1, 2015 till December 31, 2019. The 85 patients had concomitant significant (grade 2 or 3) MR. We performed logistic regression analysis of age, sex, atrial fibrillation, left ventricular ejection fraction, end diastolic diameter, end systolic diameter, left atrial diameter, left atrial area, MR etiology (functional vs. degenerative), CHA2DS2-VASc score, pre-procedure B-type natriuretic peptide (BNP) levels and type of TAVI bioprosthesis as possible predictors of post-TAVI improvement of severity of MR.

Results

The 35 patients have at least one grade reduction in the severity of MR in follow-up echo. None of the analyzed parameters were predicting of the MR severity improvement.

Conclusions

In this small single-center cohort study, we were unable to find any feasible demographic, clinical, echocardiographic or laboratory predictors of MR improvement after TAVI. There was no correlation between etiology of MR or type of TAVI bioprosthesis used and MR improvement.

Mitral regurgitation after transcatheter aortic valve replacement

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.

The Impact of Self-Expandable Transcatheter Aortic Valve Replacement on Concomitant Functional Mitral Regurgitation: A Comprehensive Engineering Analysis

Background

Mitral regurgitation (MR) is present in a large proportion of patients who undergo transcatheter aortic valve replacement (TAVR). However, existing clinical data on the impact of TAVR on early post-procedural MR severity are contradictory. Using a comprehensive computational engineering methodology, this study aimed to evaluate quantitatively the structural and hemodynamic impact of TAVR on aortic-mitral continuity and MR severity in a rigorously developed and validated patient-specific left heart (LH) computer model with aortic stenosis and concomitant functional MR.

Methods

TAVR procedure was virtually simulated using a self-expandable valve (SEV) at three implantation heights. Pre- and post-TAVR LH dynamics as well as intra-operative biomechanics were analyzed.

Results

No significant differences in early MR improvement (<10%) were noted at the three implantation depths when compared to the pre-TAVR state. The high deployment model resulted in the highest stress in the native aortic leaflets, lowest stent-tissue contact force, highest aortic-mitral angle, and highest MR reduction for this patient case. When comparing SEV vs. balloon-expandable valve (BEV) performance at an optimal implantation height, the SEV gave a higher regurgitant volume ⋅ than the pre-TAVR model (40.49 vs 37.59 ml), while the BEV model gave the lowest regurgitant volume (33.84 vs 37.59 ml).

Conclusions

Contact force, aortic-mitral angle, and valve annuli compression were identified as possible mechanistic parameters that may suggest avenues for acute MR improvement. Albeit a single patient parametric study, it is our hope that such detailed engineering analysis could shed some light into the underlying biomechanical mechanisms of TAVR impact on MR.

Successful Treatment of Mitral Regurgitation after Transapical Transcatheter Aortic Valve Implantation by Percutaneous Edge-to-edge Mitral Valve Repair (MitraClip®) -The First Combination Therapy Performed in Japan

A 75-year old man with a history of inferior myocardial infarction was admitted with symptoms of progressive heart failure 3 months after undergoing transapical transcatheter aortic valve implantation (TAVI). Echocardiography revealed severe mitral regurgitation (MR) caused by posterior leaflet tethering, without traumatic injury of the mitral valve or chordae. The patient was successfully treated by percutaneous edge-to-edge mitral valve repair (MitraClip^®). This case highlights the role of MitraClip^® in high-risk patients suffering from MR, and suggests that apical contractile loss or adhesion caused by apical puncture and suturing in transapical TAVI may be one of the mechanisms of worsening MR.

Evaluation of mitral regurgitation by an integrated 2D echocardiographic approach in patients undergoing transcatheter aortic valve replacement

The purpose of this study was to evaluate mitral regurgitation (MR) severity in patients undergoing transcatheter aortic valve replacement (TAVR) by standardized assessment of two-dimensional (2D) transthoracic echocardiography (TTE) and 1-year echocardiographic and clinical outcomes. Pre- and post-procedural TTE's of patients undergoing TAVR between 2008 and 2014 were analyzed. MR was graded according to current guidelines with a systematic and integrated approach. Longitudinal echocardiographic and clinical results were analyzed. Regression analysis was performed for change in MR grade at follow-up, using pre-determined variables and confounders. Pre- and post-procedural TTE were available in 213 subjects. Significant MR was seen in 22% at baseline and 15% at follow-up; MR grade ≥ 3 in < 10%. Severity did not change in 61%, and decreased in 20% of the patients. Overall, the prevalence of MR grades pre- and post TAVR was not significantly different, nor influenced by MR etiology or TAVR prosthesis type. However, higher MR grades and pacemaker absence at baseline, were independently correlated to more improvement of MR after TAVR. Regarding clinical outcomes, NYHA class improved in two-thirds of the patients, irrespective of the baseline MR grade. Overall survival was not significantly different amongst MR grades post-TAVR. MR grading using an systematic 2D echocardiographic approach in patients undergoing TAVR is feasible in clinical practice. Our data revealed a relatively frequent prevalence of significant MR (although grade ≥ 3 was scarce), overall no change in the MR grade at 1 year follow-up, improvement of functional NYHA class, and no significant differences in long-term survival amongst the post-TAVR MR grades.

Association of postprocedural aortic regurgitation with mitral regurgitation worsened after transcatheter aortic valve replacement

BACKGROUND

There is a paucity of investigation which demonstrates a predictor of mitral regurgitation (MR) worsened after aortic valve replacement (TAVR).

AIM

The aim of this study was to identify the predictor of worsened MR after transcatheter TAVR.

METHODS

We retrospectively studied a total of 209 patients with mild or less MR at baseline who underwent TAVR for the treatment of severe aortic stenosis with the balloon-expandable device. We found the presence of MR worsened after TAVR in 6% (12 patients) of all patients. Moderate or more postprocedural aortic regurgitation (AR) (odds ratio, 8.104; 95% confidence interval, 1.78-36.87; P = .007) was identified as a predictor of MR worsening after TAVR. In-hospital outcomes indicated that patients within whom MR worsened suffered congestive heart failure more than those with unchanged or improved MR after TAVR (P < .05).

CONCLUSION

Significant postprocedural AR was associated with MR worsened from mild or less to moderate or more after TAVR. Worsened MR might affect in-hospital congestive heart failure.

Transcatheter Aortic Valve Replacement in Patients With Aortic Stenosis and Mitral Regurgitation

BACKGROUND

Many patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis also have significant mitral regurgitation (MR). We sought to understand the association of concomitant MR with TAVR clinical outcomes, as well changes in MR after TAVR.

METHODS

Patients who underwent TAVR in the US Transcatheter Valve Therapy Registry from January 3, 2012, to December 31, 2013, were studied, with longer-term clinical outcomes from Center for Medicare Services data.

RESULTS

Of 11,104 patients, 3,481 (31.3%) had moderate MR, and 605 (5.5%) had severe MR. At 1 year, mortality was 21.0%, 21.5%, 26.3%, and 28.0% (p < 0.0001) and heart failure (HF) rehospitalization was 13.9%, 15.8%, 20.3%, and 23.4% (p < 0.0001) in the no, mild, moderate, and severe MR patients, respectively. After adjustment for baseline differences, significant MR was associated with increased risk of 1-year mortality or HF rehospitalization, with a HR of 1.16 (95% CI, 0.99 to 1.35) for moderate MR and 1.21 (95% CI, 0.97 to 1.50) for severe MR, compared with no MR. MR improved early after TAVR grade ≥ 1 in 79% of the severe MR patients and 66% of the moderate MR patients. Patients whose baseline moderate or severe MR improved had lower mortality (p = 0.022) and HF rehospitalization (p < 0.001) compared with patients whose MR did not improve.

CONCLUSIONS

Moderate or severe MR accompanying severe AS treated with TAVR is associated with increased mortality or HF rehospitalization. This increased risk may be attributable to the minority of patients whose MR does not improve, suggesting a potential role for surveillance and targeted intervention for those patients.

Impact of baseline mitral regurgitation on short- and long-term outcomes following transcatheter aortic valve replacement

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.

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

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

Mitral regurgitation prior to transcatheter aortic valve implantation influences survival but not symptoms

BACKGROUND

Current data about the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve implantation (TAVI) are conflicting. Our purpose was to analyze the clinical course of MR and to assess the influence of MR on survival and clinical status after TAVI.

METHODS

We included 375 consecutive patients who underwent TAVI. MR grade and NYHA class were determined before TAVI and at follow-up.

RESULTS

In total 171 patients (46%) had MR grade ≥ 2 at baseline and of these 29% improved to MR grade ≤ 1 after TAVI. MR grade ≤ 1 at baseline was present in 204 patients (54%) and of these 17% worsened to grade ≥ 2 after TAVI. Improvement of MR was associated with absence of atrial fibrillation (OR: 2.35, 95%CI: 1.17-4.71, p = 0.02). Worsening of MR was associated with moderate or more aortic valve regurgitation after TAVI (OR: 4.2, CI: 1.83-9.49, p = 0.001). NYHA class improved at follow-up. Baseline MR grade did not determine the degree of clinical improvement (MR grade ≤ 1: NYHA ≥ 3 from 67% to 17%; MR grade ≥ 2: NYHA ≥ 3 from 69% to 14%). Although patients with MR grade ≥ 2 at baseline improved symptomatically, this degree of MR was associated with reduced two year survival compared with patients with MR grade ≤ 1(mortality 37% vs 26%; HR 1.99; 95% CI 1.27-3.13; p = 0.003).

CONCLUSION

In patients who undergo TAVI almost half have MR grade ≥ 2 prior to the procedure. TAVI had no influence on MR grade at follow-up. Although patients with MR grade ≥ 2 at baseline improved symptomatically after TAVI, concomitant MR at baseline significantly reduced two year survival.

Clinical impact and evolution of mitral regurgitation following transcatheter aortic valve replacement: a meta-analysis

OBJECTIVES

Mitral regurgitation (MR) is a common entity in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but its influence on outcomes remains controversial. The purpose of this meta-analysis was to assess the clinical impact of and changes in significant (moderate-severe) MR in patients undergoing TAVR, overall and according to valve design (self-expandable (SEV) vs balloon-expandable (BEV)).

METHODS

All national registries and randomised trials were pooled using meta-analytical guidelines to establish the impact of moderate-severe MR on mortality after TAVR. Studies reporting changes in MR after TAVR on an individual level were electronically searched and used for the analysis.

RESULTS

Eight studies including 8015 patients (SEV: 3474 patients; BEV: 4492 patients) were included in the analysis. The overall 30-day and 1-year mortality was increased in patients with significant MR (OR 1.49, 95% CI 1.16 to 1.92; HR 1.32, 95% CI 1.12 to 1.55, respectively), but a significant heterogeneity across studies was observed (p<0.05). The impact of MR on mortality was not different between SEV and BEV in meta-regression analysis for 30-day (p=0.360) and 1-year (p=0.388) mortality. Changes in MR over time were evaluated in nine studies including 1278 patients. Moderate-severe MR (SEV: 326 patients; BEV: 192 patients) improved in 50.5% of the patients at a median follow-up of 180 (30-360) days after TAVR, and the degree of improvement was greater in patients who had received a BEV (66.7% vs 40.8% in the SEV group, p=0.001).

CONCLUSIONS

Concomitant moderate-severe MR was associated with increased early and late mortality following TAVR. A significant improvement in MR severity was detected in half of the patients following TAVR, and the degree of improvement was greater in those patients who had received a BEV.

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

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.

Meta-analysis of mortality outcomes and mitral regurgitation evolution in 4,839 patients having transcatheter aortic valve implantation for severe aortic stenosis

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.

Impact of preprocedural mitral regurgitation upon mortality after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis

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.

The change in mitral regurgitation severity after trans-catheter aortic valve implantation

BACKGROUND

Mitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). The objective of this study is to assess the change in MR severity following transcatheter aortic valve implantation (TAVI).

METHODS

MR changes were assessed by comparing transthoracic echocardiography before and after the procedure.

RESULTS

The prosthetic aortic valve was successfully implanted in 65 patients. The number of patients with pre-procedure MR was reduced from 58 (85.3%) to 43 (63.2%) (p < 0.001). Vena contracta width was decreased from 0.47 ± 0.28 to 0.25 ± 0.21, (p = 0.043). About 59.4% (19/32) of those who had moderate to severe MR and 85.7% (12/14) of those with severe MR experienced a significant improvement in MR after the procedure (p < 0.001). Improvement in MR was independent of prosthetic valve type with 54.2% in CoreValve and 43.9% in Edwards SAPIEN, p = 0.424; valve sizes were 25.8 ± 1.9 in those who improved vs. 25.0 ± 1.9 mm in those who did not improve, p = 0.105; femoral approach was 51.2% and apical approach was 41.7%, p = 0.457; MR etiology was 48.1% in organic and 48.6% in functional, p = 0.968; and operative risk was 50.0% in EuroScore >20 and 48.6% in EuroScore <20, p = 0.356.

CONCLUSIONS

TAVI is associated with a significant improvement in MR, especially in severe types. The lack of influence of MR improvement by the etiology of MR, the type of valve implanted, and the operative risk need to be confirmed in a larger multi-center study.

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

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

Evolution of Transcatheter Aortic Valve Replacement

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.

Effect of Transcatheter Aortic Valve Replacement on the Mitral Valve Apparatus and Mitral Regurgitation

Background—

The effect of transcatheter aortic valve replacement (TAVR) on the mitral valve apparatus and factors influencing the reduction of mitral regurgitation with or without mitral leaflet tethering after TAVR are poorly understood. The present 3-dimensional (3D) transesophageal echocardiography study aimed to elucidate early changes further in the structure and function of the mitral valve apparatus after TAVR.

Methods and Results—

We analyzed 90 patients (nontenting group, 56 patients and tenting group, 34 patients) who underwent TAVR using the Edwards SAPIEN and had intraprocedural 3D transesophageal echocardiography evaluation of the mitral valve. Of all patients, mitral regurgitation improved in 54%, remained the same in 38%, and worsened in 8% 1 day after TAVR. There were no statistically significant differences in mitral annular 3D parameters before and after TAVR in both groups. In the tenting group, tenting area ( P <0.01) and tenting height ( P <0.01) were decreased, and coaptation length was increased ( P <0.05) after TAVR. In a multivariable analysis, the predictors of improved mitral regurgitation were the decrease of tenting area (odds ratio, 8.15; 95% confidence interval, 1.31–50.7; P <0.05) and the decrease of valvuloarterial impedance (odds ratio, 7.57; 95% confidence interval, 1.15–49.9; P <0.05) in the tenting group and the decrease of valvuloarterial impedance (odds ratio, 6.96; 95% confidence interval, 1.24–39.2; P <0.05) in the nontenting group.

Conclusions—

Mitral leaflet tethering was improved immediately by TAVR in patients with mitral leaflet tenting regardless of mitral annular geometry. Acute improvement in mitral regurgitation after TAVR is predominantly related to global left ventricular hemodynamics and mitral leaflet tethering change.

Transcatheter aortic valve implantation reduces grade of concomitant mitral and tricuspid valve regurgitation and pulmonary hypertension

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.

Incidental moderate mitral regurgitation in patients undergoing aortic valve replacement for aortic stenosis: review of guidelines and current evidence

Recent evidence has shown that moderate mitral regurgitation is common and clinically relevant in patients presenting for surgical and transcatheter aortic valve replacement for aortic stenosis. Prospective multicenter clinical trials are now indicated to resolve the clinical equipoise about whether or not mitral valve intervention also is indicated at the time of aortic valve intervention. Advances in three-dimensional transesophageal echocardiography, transcatheter mitral interventions, and surgical aortic valve replacement, including the advent of sutureless valves, likely will expand the therapeutic possibilities for moderate mitral regurgitation in the setting of aortic valve interventions for severe aortic stenosis.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Long-term Doppler hemodynamics and effective orifice areas of Edwards SAPIEN and medtronic CoreValve prostheses after TAVI

BACKGROUND

Although initial hemodynamics of percutaneously implanted aortic bioprostheses compare favorably to surgically implanted valves, the durability of the flow characteristics remains unknown. As biological prostheses are at potential risk for early degeneration, the aim of our study was to compare Doppler hemodynamics and effective orifice area (EOA) directly after and at least 1 year after valve implantation.

METHODS

In this monocentric, prospective study, we determined peak velocity, peak and mean systolic gradients, and EOA by echocardiography in 75 patients (Edwards SAPIEN, n = 20; CoreValve, n = 55) 1 week (median 7 ± 25 days) and 1 year (median 378 ± 157 days, maximum 1034 days) after transcatheter aortic valve implantation (TAVI).

RESULTS

After 12 months, Doppler performance of the aortic valve prostheses remained unchanged. The peak instantaneous velocity was 1.9 ± 0.4 m/s directly after TAVI versus 1.8 ± 0.5 m/s (P = ns) at follow-up, with a mean gradient of 8.5 ± 3.7 mmHg and 8.1 ± 4.2 (P = ns), respectively. Interestingly, the degree of mitral regurgitation (MR) decreased significantly (P = 0.007) over time, and the severity of aortic regurgitation (AR) remained unchanged during follow-up (P = ns).

CONCLUSION

For at least 1 year after TAVI, the excellent Doppler hemodynamics and EOA are preserved in transcatheter aortic valve prostheses, and the severity of MR decreased significantly. In addition, we found no evidence of early valve deterioration or progression of AR.

Transfemoral aortic valve implantation in patients with an annulus dimension suitable for either the Edwards valve or the CoreValve

The aim of this study was to compare the outcomes of transcatheter aortic valve implantation using the Edwards SAPIEN valve and the Medtronic CoreValve in patients with annulus of intermediate size (20 to 25 mm). From October 2008 to April 2012, 662 consecutive patients who underwent transcatheter aortic valve implantation were studied at 2 French centers. After propensity score matching, a total of 192 patients with intermediate-sized aortic annulus who had received either Edwards (n = 96, mean age 82.4 ± 7.9 years, 48% men, 61.9% receiving the 26-mm valve) or CoreValve (n = 96, mean age 82.5 ± 7.7 years, 50% men, 64.6% receiving the 29-mm valve) prostheses through the transfemoral approach were studied. Adequate reduction in postprocedural mean pressure gradients was achieved with the Edwards valve and the CoreValve (10.9 ± 4.7 vs 9.1 ± 4.4 mm Hg, respectively, p <0.01). Major vascular complications (5.2% vs 3.1%, p = 0.36), device success (95.8% vs 93.8%, p = 0.52), and 30-day survival (90.6% vs 89.6%, p = 0.81) were similar. The incidence of postprocedural aortic regurgitation grade ≥2/4 and new pacemaker implantation was more frequent in the CoreValve group (14.3% vs 35.5%, p <0.01, and 4.2% vs 18.8%, p <0.01, respectively). There was no significant difference in 1-year cumulative survival rates in the Edwards valve group compared with the CoreValve group (80.1 ± 4.2% vs 75.6 ± 4.9%, log-rank p = 0.31). In conclusion, in patients with annulus of intermediate size, similar device success and short-term and midterm outcomes were achieved with either of the valves, irrespective of the specific complications related to each valve.