Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

Abstract

Objective The objective of this study was to assess imaging predictors of mitral regurgitation (MR) improvement and to evaluate the impact of MR regression on long-term outcome in patients undergoing transcatheter aortic valve replacement (TAVR). Background Concomitant MR is a frequent finding in patients with severe aortic stenosis but usually left untreated at the time of TAVR. Methods Mitral regurgitation was graded by transthoracic echocardiography before and after TAVR in 677 consecutive patients with severe aortic stenosis. 2-year mortality was related to the degree of baseline and discharge MR. Morphological echo analysis was performed to determine predictors of MR improvement. Results 15.2% of patients presented with baseline MR ≥ 3 +, which was associated with a significantly decreased 2-year survival (57.7% vs. 74.4%, P < 0.001). MR improved in 50% of patients following TAVR, with 44% regressing to MR ≤ 2 +. MR improvement to ≤ 2 + was associated with significantly better survival compared to patients with persistent MR ≥ 3 +. Baseline parameters including non-severe baseline MR, the extent of mitral annular calcification and large annular dimension (≥ 32 mm) predicted the likelihood of an improvement to MR ≤ 2 +. A score based on these parameters selected groups with differing probability of MR ≤ 2 + post TAVR ranging from 10.5 to 94.4% (AUC 0.816; P < 0.001), and was predictive for 2-year mortality. Conclusion Unresolved severe MR is a critical determinant of long term mortality following TAVR. Persistence of severe MR following TAVR can be predicted using selected parameters derived from TTE-imaging. These data call for close follow up and additional mitral valve treatment in this subgroup.Matti Adam and Henrik ten Freyhaus contributed equally.Matti Adam and Henrik ten Freyhaus share jointly co-directed this work and share the last authorship of this work. Electronic supplementary materialThe online version of this article (https ://doi. Graphic abstractFactors associated with MR persistence or regression after TAVR

Change in mitral regurgitation severity after transcatheter aortic valve replacement in patients with severe mitral regurgitation

“…(n = 2), respectively. Namely, this study included predominantly patients with moderate rather than severe MR. And it's reported by Mauri et al 2 that concomitant severe MR at baseline was related to significantly higher mortality. However, the evolution of severe MR after TAVR and its impact on long-term survival remains uncertain.…”

The Prognosis of Baseline Mitral Regurgitation in Patients with Transcatheter Aortic Valve Implantation

“…The lack of information in the specific grading of atrioventricular regurgitation limits the potential extrapolation of the findings from current study into pre-operative risk assessment of TAVI candidates, given the significant different prognostic profile between those with insignificant (none or mild) and significant (moderate or severe) MR or TR [36,37]. Meanwhile, the regression of significant baseline MR and TR was observed in approximately 50-60% of TAVI patients following the procedure, and the post-procedurally regression in regurgitation was significantly associated with better clinical outcomes [36,38]. The unavailability of the dynamic changes of atrioventricular regurgitation over the time course in our study limits further in-depth analysis of the risk factors contributing to prognosis post TAVI.…”

“…An accurate assessment and grading of the regurgitation in those with baseline mitral and tricuspid regurgitation were unavailable in current study. Increased severity of baseline mitral and tricuspid regurgitation is associated with stepwise increase in shortterm comorbidities and worse long-term survival, as well as more rehospitalization for HF in TAVI recipients [36,37]. The lack of information in the specific grading of atrioventricular regurgitation limits the potential extrapolation of the findings from current study into pre-operative risk assessment of TAVI candidates, given the significant different prognostic profile between those with insignificant (none or mild) and significant (moderate or severe) MR or TR [36,37].…”

“…Increased severity of baseline mitral and tricuspid regurgitation is associated with stepwise increase in shortterm comorbidities and worse long-term survival, as well as more rehospitalization for HF in TAVI recipients [36,37]. The lack of information in the specific grading of atrioventricular regurgitation limits the potential extrapolation of the findings from current study into pre-operative risk assessment of TAVI candidates, given the significant different prognostic profile between those with insignificant (none or mild) and significant (moderate or severe) MR or TR [36,37]. Meanwhile, the regression of significant baseline MR and TR was observed in approximately 50-60% of TAVI patients following the procedure, and the post-procedurally regression in regurgitation was significantly associated with better clinical outcomes [36,38].…”

Response—Letter to the editor "Change in Mitral Regurgitation Severity after Transcatheter Aortic Valve Replacement in Patients with Severe Mitral Regurgitation"

“…Second, the authors point out that a majority of patients undergoing transcatheter aortic valve replacement (TAVR) in our population suffered from moderate rather than severe mitral regurgitation (MR), and that it was, therefore, impossible to draw sound conclusions on the evolution of severe MR following TAVR. They also note that studying said evolution would be of worth given that a study published by Mauri et al 2 in 2020 previously suggested that severe MR at baseline was associated with significantly worse outcomes in patients undergoing TAVR. The authors then report the results of a study led by them at Guangdong Provincial People's Hospital that included 43 patients with severe MR undergoing TAVR.…”