Impact of severe mitral regurgitation on postoperative outcome after durable left‐ventricular assist device implantation

Abstract

Background: Mitral valve regurgitation (MR) is a common finding in patients with end-stage heart failure. The aim of the study was to analyze the impact of preoperative moderate-to-severe MR on postoperative outcomes and survival after durable left-ventricular assist device (LVAD) implantation. Methods:From August 2010 to May 2021, 246 patients underwent a durable LVAD implantation. We stratified the patients into two groups: Group A (n = 109) presented with MR 0-I°, and Group B presented with MR II-III° (n = 137). MR II-III° was defined according to the current recommendations (i.e., vena contracta ≥ 7 mm, regurgitation volume ≥ 30 ml or effective regurgitation orifice area ≥ 20 mm 2 ).Results: Significantly more patients in Group B suffered from pulmonary hypertension and presented with chronic obstructive lung disease. We observed significantly higher rates of tricuspid regurgitation (TR) II-III° in Group B (76.1%) versus Group A (14.8%) (p < 0.001) and TR III° in Group B (30.4%) versus Group A (3.7%) (p < 0.001). There was no difference in the incidence of right heart failure between the groups. Within our cohort, the in-hospital, 1-year, 3-year, and 5year mortality was 22.4%, 32.1%, 50.7%, and 64.4%, respectively. Group B showed significantly worse overall survival (p = 0.05). Patients with preoperative TR II-III° had a significantly worse survival than those with TR 0-I° (p = 0.048). In patients presenting with MR II-III°, we discovered that TR III° seems to predict both in-hospital and mid-term mortality. Conclusion: MR II-III° negatively affects the outcomes in patients requiring LVAD implantation. Persisting MR II-III° is an independent predictor of mortality. Patients with concomitant preoperative TR II-III° are at increased risk of This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Left ventricular assist device implantation and concomitant mitral valve surgery: A systematic review and meta‐analysis

“…Whilst our recently published meta‐analysis showed that the degree of pre‐operative MR does not appear to affect mortality in patients receiving LVAD, 24 the same cannot be said for post‐operative MR with several studies linking it to worse clinical outcomes, 25,26 a conclusion which was also reached by the recently published study by Loforte and colleagues 27 . Interestingly, the study by Loforte et al 27 .…”

“…8,[19][20][21][22] This is believed to be a result of improving the haemodynamics of the left ventricle thus lowering the left ventricular enddiastolic diameter (LVEDD) and therefore reducing the severity of MR. 23 It is most likely because of this, that we did not find increased survival in the LVAD + MVR group. Whilst our recently published meta-analysis showed that the degree of pre-operative MR does not appear to affect mortality in patients receiving LVAD, 24 the same cannot be said for post-operative MR with several studies linking it to worse clinical outcomes, 25,26 a conclusion which was also reached by the recently published study by Loforte and colleagues. 27 Interestingly, the study by Loforte et al 27 surprisingly demonstrates that LVAD implantation in patients with significant preoperative MR without concomitant mitral valve surgery leads to better survival and morbidity outcomes compared to those with mild or no MR.…”

Prognostic value of mitral regurgitation in patients undergoing left ventricular assist device deployment: A systematic review and meta‐analysis

“…Of these, 340 relevant articles were read in full and assessed according to our inclusion and exclusion criteria. Following critical appraisal, a total of 19 studies [7][8][9][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] incorporating a total of 11 873 patients were included. The studies described outcomes of patients undergoing LVAD implantation with either MR grade 0-I (8819 patients) or II-III (3096 patients).…”

“…52 Future efforts should focus on reducing adverse outcomes in high-risk groups, 53 such as those with concomitant TR. 54 Zuberevich et al 8 suggested the potential benefits of operative TR resolution in cases where it accompanies severe levels of pre-operative MR.…”

“…It also remains unclear whether the degree of severity of baseline MR pre‐LVAD may drive these varying trajectories of MR resolution. LVAD has previously been shown to have a promising role in improving MR following deployment, 7,8 yet, this is not completely efficacious, with multiple cases where MR persists post‐LVAD seen in the literature 9 . The potential of concomitant mitral intervention to prevent this remains controversial 10 .…”