Previous TAVR in patients undergoing percutaneous edge-to-edge mitral valve repair (PMVR) affects improvement of MR

Two-Year Clinical Outcomes of Staged Transcatheter Mitral Edge-to-Edge Repair After Transcatheter Aortic Valve Replacement

Residual significant mitral regurgitation (MR) can increase the risk of adverse events after transcatheter aortic valve replacement (TAVR). The clinical benefits of staged transcatheter edge-to-edge repair (TEER) after TAVR remain underexplored. This study aimed to investigate the clinical outcomes of staged TEER for residual significant MR after TAVR. This observational study included 314 consecutive patients with chronic residual grade 3+ or 4+ MR at the 30-day follow-up after TAVR, with 104 patients (33.1%) treated with staged TEER (TEER group) and 210 (66.9%) with medical therapy alone. The primary composite outcomes were all-cause mortality and heart failure hospitalization at 2 years. Additional analysis, including changes in MR grade and the New York Association functional classification, and subgroup outcome comparisons based on MR etiology were also conducted. In our study, the rate of primary composite outcome was lower in the TEER group than in the medical therapy alone group (33.7% vs 48.1%, p = 0.015). Significant improvement in MR grade and New York Association class was observed in the TEER group after 2 years. The subgroup analysis demonstrated that in patients with degenerative MR, a lower incidence of composite outcome and heart failure hospitalization was observed in the TEER group (hazard ratio 0.35, 95% confidence interval 0.23 to 0.53, p <0.001). In conclusion, staged TEER after TAVR was associated with reduced MR and improved clinical outcomes. The clinical significance of MR after TAVR should be carefully evaluated, and TEER should be considered for patients with significant residual MR, particularly, those with degenerative MR.

Impact of pulmonary hypertension on outcomes after TEER in patients suffering from mitral regurgitation

AIM

Data on associations of invasively determined hemodynamic parameters with procedural success and outcomes in patients suffering from mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair of the mitral valve (M-TEER) is limited.

METHODS AND RESULTS

We enrolled 239 patients with symptomatic MR of grade 2 + , who received M-TEER. All patients underwent extensive pre-interventional invasive hemodynamic measurements via right heart catheterization (mean pulmonary arterial pressure (mPAP), systolic- (PAPsys) and diastolic pulmonary arterial pressure (PAPdia), pulmonary arterial wedge pressure (PAWP), a-wave, v-wave, pulmonary vascular resistance (PVR), transpulmonary pressure gradient (TPG), cardiac index (CI), stroke volume index (SVI)). mPAP and PAWP at baseline were neither associated with procedural success, immediate reduction of MR, nor residual MR after 6 months of follow-up. The composite outcome (All-cause mortality (ACM) and/or heart failure induced rehospitalization (HFH)) and HFH differed significantly after M-TEER when stratified according to mPAP, PAWP, PAPdia, a-wave and v-wave. ACM was not associated with the afore mentioned parameters. Neither PVR, TPG, CI nor SVI were associated with the composite outcome and HFH, respectively. In multivariable analyses, PAWP was independently associated with the composite outcome and HFH. PVR and SVI were not associated with outcomes.

CONCLUSION

PAWP at baseline was significantly and independently associated with HFH and might serve as a valuable parameter for identifying patients at high risk for HFH after M-TEER. ACM and procedural success were not affected by pulmonary arterial pressure before M-TEER. We suggest that the post-capillary component of PH serves as the driving force behind the risk of HFH.

Transcatheter Aortic Valve Replacement as a bridge to minimally invasive endoscopic mitral valve surgery in Elderly Patients in the era of ERAS and Fast Track TAVI concepts

In this bicentric study, we report the outcomes of combined transcatheter aortic valve replacement combined with minimally invasive mitral valve surgery. We included a cohort of six patients (79.6 ± 3.2 years, 83% women) with high-risk profiles and deemed to be non-operable with combined mitral and aortic valvular disease. All patients had unsuitable anatomies for transcatheter mitral valve edge-to-edge repair (TEER). Moreover, most of the patients (5/6) suffered a combined aortic valve lesion, which complicates the efficiency of cardioplegia in the case of CBP through minimally invasive incisions. The first stage was implanting a TAVI valve to achieve aortic valve competency and hence facilitate the infusion of cardioplegia after clamping the aorta during endoscopic mitral valve surgery. After one week, we performed the minimally invasive mitral valve repair. Most patients (n = 5; 83%) underwent successful endoscopic mitral valve repair. Intraoperatively, the mean ischemic time was 42 min, and the total bypass time was 72 min. Postoperatively, the mean intubation time was 0 h. Postoperative complications included reoperation for bleeding in one patient (16.7%) and a new heart block requiring pacemaker implantation in one patient (16.7%). There was neither in-hospital mortality nor 1-year mortality.

Transcatheter mitral valve implantation using the Tendyne valve in a patient with prior transcatheter aortic valve implantation: a case report

Background

The presence of aortic and mitral disease in a patient who is not a suitable candidate for surgical correction poses significant challenges in the diagnostic workup as well as management plans. Percutaneous treatment can be staged to fix the aortic valve with transcatheter aortic valve implantation (TAVI) as a first step, followed by reassessment and percutaneous correction of mitral regurgitation (MR).

Case summary

A 65-year-old female with multiple co-morbidities presented with acute coronary syndrome and heart failure. She was diagnosed with three-vessel coronary artery disease and degenerative low-flow low-gradient severe aortic stenosis, along with severe degenerative MR with a left ventricular ejection fraction of 35%. Because of the high surgical risk, she underwent multi-vessel percutaneous coronary intervention with stenting. Transcatheter aortic valve implantation was done as a staged procedure, which partially improved her symptoms. Mitral regurgitation was not suitable for percutaneous mitral valve edge-to-edge repair. After a discussion by the heart team, she underwent transcatheter mitral valve implantation, for which the Tendyne mitral valve (Tendyne™; Abbott) was used through a transapical approach. There was no paravalvular leak, and the mean gradient across the valve was 2 mmHg. She was symptomatically better at follow-up and an echocardiogram showed a normally functioning aortic valve and Tendyne mitral valves.

Discussion

Transapical transcatheter mitral valve implantation using the Tendyne valve is a feasible option for patients with prior TAVI. This can be considered an alternative treatment for MR in patients who are not suitable for edge-to-edge mitral repair.

Improved mid-term stability of MR reduction with an increased number of clips after percutaneous mitral valve repair in functional MR

Background

Percutaneous mitral valve repair (PMVR) has evolved to be a standard procedure in suitable patients with mitral regurgitation (MR) not accessible for open surgery. Here, we analyzed the influence of the number and positioning of the clips implanted during the procedure on MR reduction analyzing also sub-collectives of functional and degenerative MR (DMR).

Results

We included 410 patients with severe MR undergoing PMVR using the MitraClip® System. MR and reduction of MR were analyzed by TEE at the beginning and at the end of the PMVR procedure. To specify the clip localization, we sub-divided segment 2 into 3 sub-segments using the segmental classification of the mitral valve.

Results

We found an enhanced reduction of MR predominantly in DMR patients who received more than one clip. Implantation of only one clip led to a higher MR reduction in patients with functional MR (FMR) in comparison to patients with DMR. No significant differences concerning pressure gradients could be observed in degenerative MR patients regardless of the number of clips implanted. A deterioration of half a grade of the achieved MR reduction was observed 6 months post-PMVR independent of the number of implanted clips with a better stability in FMR patients, who got 3 clips compared to patients with only one clip.

Conclusions

In patients with FMR, after 6 months the reduction of MR was more stable with an increased number of implanted clips, which suggests that this specific patient collective may benefit from a higher number of clips.

The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

Heart failure following transcatheter aortic valve replacement

Introduction: Over the past decade, the number of transcatheter aortic valve replacement (TAVR) procedures has increased exponentially. Despite major improvements in both device and successes, the rate of hospital readmission after TAVR remains high, with heart failure (HF) decompensation being one of the most important causes.Areas covered: This review provides an overview of the current status of HF following TAVR, including details about its incidence, clinical impact, contributing factors, and current and future treatment perspectives.Expert opinion: HF decompensation has been identified as the most common cause of rehospitalization following TAVR, and it has been associated with a negative prognosis. Multiple preexisting factors including low flow status, cardiac amyloidosis, myocardial fibrosis, multivalvular disease, pulmonary hypertension, coronary artery disease, and atrial fibrillation have been associated with an increased risk of HF events. Also, multiple post-procedural factors like the occurrence of significant paravalvular leaks, severe prosthesis-patient mismatch, and conduction disturbances have also contributed to increase this risk . Thus, reducing HF events in TAVR recipients would require a multifactorial and multidisciplinary effort including the optimization of the medical treatment and close follow-up and treatment of residual or concomitant valvular disease and conduction disturbance issues. Future studies in this challenging group of patients are warranted.

Predictors and Outcome Impact of Mitral Regurgitation in Transcatheter Aortic Valve Replacement

BACKGROUND/PURPOSE

Several studies have reported that mitral regurgitation (MR) can improve following transcatheter aortic valve replacement (TAVR) alone using earlier-generation valves. The purpose of this study was to determine the predictors and short-term outcome impact of MR in patients undergoing TAVR using all generation valves across all risk groups.

METHODS/MATERIALS

In this retrospective, study from 2012 to 2020, we reviewed data on 1822 low-, intermediate-, and high-risk patients who underwent TAVR. Included were 1266 patients with baseline MR who underwent transfemoral TAVR. Our primary outcome was persistence or worsening of baseline MR post-TAVR. Additional endpoints included an inpatient composite (intensive care unit length of stay >24 h, post-TAVR length of stay >2 days, and inpatient death), 30-day composite (30-day death or readmission), and 1-year composite (1-year death or readmission).

RESULTS

Of the 1266 patients included, 665 had significant baseline MR (≥moderate), which improved in 79.4% of patients (n=528). Female patients, those with lower body mass indices, and those with higher right ventricular systolic pressures were more likely to have persistence or worsening of baseline MR. Patients whose baseline MR persisted or worsened, had higher rates (80.3% vs. 77.3%, p=0.0019) of our inpatient composite, higher rates (15.3% vs. 10.0%, p=0.0389) of our 30-day composite, and higher rates (36.7% vs. 26.8%, p=0.0107) of our 1-year composite when compared to patients whose baseline MR improved post-TAVR.

CONCLUSIONS

Our study identifies clinical characteristics, which help identify patients who may require closer post-procedural follow-up and warrant possible staged mitral valve intervention post-TAVR across all risk groups.