P752 Mitral regurgitation in patients with severe aortic stenosis: role of valvular calcification in the persistence of mitral regurgitation after aortic valve replacement

Abstract

Introduction mitral regurgitation is often associated with severe aortic stenosis but the indications for its correction at the time of aortic valve surgery are still unclear. Despite the indication for mitral valve repair or replacement in the case of severe secondary mitral regurgitation, many patients are left untreated. This is due to the common belief that secondary mitral regurgitation mostly improves after the aortic valve is treated. Purpose the aim of the study is to investigate the prevalence and distribution of mitral calcifications, their role in the development of mitral regurgitation and in its reduction after aortic valve replacement. Methods we reviewed all patient’s records who underwent aortic valve replacement for aortic stenosis at our institution from 12/2014 to 12/2016. Pre and post-operative echocardiograms were reviewed by experienced echocardiographer. Patients were then divided into 4 categories (functional, mild, moderate and severe calcification) on the basis of the presence, distribuition and severity of calcification on the mitral apparatus. Results at the end 651 patients were collected and analyzed. Mean age was 74yo. 334 (51,4%) of them were males. Most patients (63,1%) had only mild mitral regurgitation but 147 (22,6%) of them had moderate or severe mitral regurgitation. The presences of moderate or severe calcification of the mitral apparatus resulted to be a risk factor for the presence of mitral regurgitation associated with aortic stenosis as shown in Table 1. After surgical aortic valve replacement less than 21% of the patients showed a reduction of the degree of mitral regurgitation. We found no statistical difference between groups about mitral regurgitation changes after aortic valve replacement. Conclusions Mitral regurgitation is a common finding in patients with severe aortic stenosis and it’s prevalence is higher in patients with mitral calcifications. Few patients, however showed a reduction in the degree of mitral regurgitation after surgical aortic valve replacement with no difference related to the severity of annular or leaflets calcifications. TABLE 1 Logistic regression for the presence of mitral regurgitation Mitral Regurgitation Change after Aortic Valve Replacement CALCIFICATION DEGREE OR C.I. 95% p Reduced p Unchanged p Increased p Functional 53(21%) 176(71%) 18(7%) Mild 1.244571 0.81 - 1.93 0.32 28(20%) 0.86 105(76%) 0.43 6(4%) 0.34 Moderate 1.637297 1.05 - 2.56 0.03* 25(17%) 0.41 109(76%) 0.34 9(6%) 0.86 Severe 2.369245 1.46 - 3.85 <0.01* 29(25%) 0.48 78(68%) 0.67 7(6%) 0.86 OR= Odds Ratio; C.I.=Confidence Interval; Functional= no calcification; Mild, Moderate and Severe= degree of mitral annular and leaflets calcifications.

New or Worsened Mitral Regurgitation After Surgical Aortic Valve Replacement: A Systematic Review

“…Of the 36 studies, 1,3,15,16, 28 studies 3,15,16,19-23-26,28-31, 33-35,38-41,44-48,50 were classified as case reports and 8 studies 1,27,32,36,37,42,43,49 were classified as retrospective studies. Across all studies, a total of patients underwent SAVR.…”

“…Across all studies, a total of patients underwent SAVR. The type of prosthesis used differed between the included studies, with 13 3,20,21,[23][24][25][26]30,33,39,41,44,47 implanting a bioprosthesis, 8 15,16,19,29,34,35,40,42 implanting a mechanical prosthesis, and 3 1,36,37 implanting mechanical and biological protheses; 12 studies 22,27,28,31,32,38,43,45,46,[48][49][50] did not specify prosthesis type. The size of the implanted prosthesis ranged from 17 mm 45 to 27 mm 20,24 ; however, 14 studies 1,[27][28][29]31,32,36,37,43,[46][47]…”

“…The risk of bias assessment for the included studies in this review can be seen in Table 2. The methodology of all 8 included retrospective observational studies 1,27,32,36,37,42,43,49 was categorized as good in accordance with the NOS rating scale. 12 Specifically, 4 studies 1,37,42,43 earned 4 out of 4 possible stars, and 4 studies 27,32,36,49…”

“…The etiology of MR was reported for 120 3,15,16,[19][20][21][22][23][24][25][26][28][29][30][31]33,34,[39][40][41][42][43][44][45][46][47][48][49][50] of the 207 cases of new or worsened MR following SAVR (Table 3). Notably, the mechanism of new or worsened MR was unspecified in the remaining 87 patients.…”

“…Notably, the mechanism of new or worsened MR was unspecified in the remaining 87 patients. 1,27,32,36,37,42,43 Organic Etiology. A total of 15.97% (20/120) of reported MR were classified as organic (ie, Carpentier's Type I or Type II), with 70.00% (14/20) 15,16,19,22,23,28,31,34,41,44,46,49 being classified as Type I, and 30.00% (6/20) 21,40,45,46 being classified as Type II.…”