Significant mitral regurgitation in patients undergoing TAVR: Mechanisms and imaging variables associated with improvement

Abstract

Background Significant mitral regurgitation (MR) is associated with poorer outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). Factors associated with MR improvement have not been studied thoroughly. Methods Retrospective analysis of consecutive patients treated with TAVR with more than mild MR at baseline. MR evolution was assessed at 1–3 and 6–12 months after intervention. MR severity and mechanisms were assessed by echocardiography. Mitral annulus calcification (MAC) was quantified using preoperative cardiac CT. Results From 674 consecutive TAVR recipients, 78 with more than mild MR had a 6–12 months follow‐up. Following TAVR, MR improved in 34 patients (43%), remained stable in 38 (49%) and worsened in 6 (8%). Patients with MR improvement had greater tenting area (141 ± 56 vs. 99 ± 40 mm2, P < 0.01), tenting height (7.2 ± 1.9 vs. 5.6 ± 1.9 mm, P < 0.01) and lower ejection fraction (43 ± 16 vs. 52 ± 14%, P = 0.01). MAC was frequent (87.7% of patients) and a trend in greater MAC was observed in patients without MR improvement (3560 ± 5587 vs. 2053 ± 2800, P = 0.16). In multivariable analysis, tenting area (OR per 10 mm2 increase: 1.012, 95% CI, 1.001–1.024 P = 0.039) and annulus calcifications associated with leaflet restriction (OR = 0.108, 95% CI, 0.012–0.956, P = 0.045) were independently associated with MR outcome after TAVR. Conclusion Larger mitral valve tenting area was associated with more improvement of MR after TAVR whereas extensive MAC associated with leaflet restriction was associated with less improvement. This may help in the clinical decision‐making process of TAVR candidates with concomitant MR.

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

“…Consequently, objective imaging parameters are needed for a detailed morphological description of the mitral valve apparatus. Several smaller studies proposed different imaging features suggestive of functional MR including greater tenting area and larger left ventricular dimensions as predictors or MR improvement [21][22][23][24]. Similarly, in our study a larger mitral annulus was a predictor of MR improvement.…”

“…Mitral annular calcification (MAC), suggestive of advanced degenerative valve disease, is associated with restricted leaflet motion, reduced annular contraction and subsequent valvular dysfunction [25,26]. MAC was previously noted as a predictor of MR persistence after TAVR [17,22,27] and as an independent predictor of mortality [28]. Similarly, in our study, MAC as assessed by TTE was a relevant predictor of MR persistence.…”

Assessment of the predictors of persistence/progression of functional mitral insufficiency in patients undergoing the interventional treatment of aortic valve diseases

“…Согласно данным O. Chiche и соавт., после транскатетерной замены АК митральная регургитация уменьшилась у 43,6% пациентов (n = 34), не изменилась у 48,7% (n = 38) и увеличилась у 7,7% (n = 6) [14]. В группе пациентов с регрессом МН отмечены большая площадь втяжения створок, высота втяжения и меньшая фракция выброса ЛЖ.…”

“…Аналогичные результаты получены в предыдущих работах, согласно которым у пациентов с протезированием АК, систолической дисфункцией ЛЖ, дилатацией ЛЖ и увеличением площади втяжения створок отмечалось уменьшение степени МН [24,25]. По данным многофакторного анализа, у подавляющего большинства пациентов был распространенный кальциноз, преимущественно заднего кольца, который ассоциировался с отсутствием изменений степени МН после транскатетерной замены АК [14]. При мно-гофакторном анализе сочетание площади тентинга и кальциноза митрального кольца с рестрикцией створок ассоциировались с меньшим регрессом МН после транскатетерной замены аортального клапана.…”

“…По данным большинства авторов, после транскатетерной замены АК выявлен регресс митральной недостаточности, однако в ряде исследований существует доля пациентов, у которых отмечается персистирование или даже прогрессирование [8,10,14].…”