Invited Commentary

Abstract

The article by Mavromatis and colleagues [1Mavromatis K. Thourani V.H. Stebbins A. et al.Transcatheter aortic valve replacement in patients with aortic stenosis and mitral regurgitation.Ann Thorac Surg. 2017; 104: 1977-1986Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar] on transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis and mitral regurgitation (MR) is a very important study and brings out several observations. It is based on a retrospective analysis of more than 11,000 patients undergoing TAVR, wherein more than 4,000 patients had moderate or severe MR, did not undergo any procedure, and experienced a higher mortality compared with those who did not have any MR. In addition, the authors also observed a reduction in mortality when the preoperative grade of MR decreased after TAVR. In residual lesions after cardiac surgical procedures, uncorrected lesions and ignored lesions contribute to a higher mortality and poorer outcomes. This has been well known for as long as cardiac surgery has existed. Then why did the TAVR team not consider correcting moderate or severe MR as the study progressed and patients died as a result of uncorrected MR? Did they not observe those outcomes until this study? If the patients who accepted to receive TAVR had known that the outcome would be worse if MR were not corrected, would they have consented to the procedure? The authors have tried their best to answer these questions in describing the limitations and in other parts of the text. The important message from this study is that patients undergoing TAVR who have hemodynamically significant MR or who experience MR after TAVR should be considered for an appropriate catheter-based correction, when it is considered that these patients are inoperable and have restrictive comorbidities. Also, the cause of MR is very important information to enable the appropriate decision to be made. Functional MR due to structural abnormalities in the ventricle may improve, but organic MR is unlikely to do so. It is therefore very essential to identify the cause of MR both for prediction of outcomes and for decision making on the appropriate procedure(s). Currently, many procedures are specifically suited to reduce or correct MR by transcatheter techniques and need to be considered in the initial evaluation of such patients’ conditions. A mitral clip for functional MR and more sophisticated procedures for degenerative MR may be considered if an operation is contraindicated. Perhaps high-risk surgical procedures for combined lesions or a hybrid procedure may be the appropriate answer. These can be answered only when a randomized comparison can be made with surgical and catheter-based interventions. Ignoring this additional lesion would significantly worsen the outcomes, especially the mortality and morbidity associated with heart failure. In addition, the very purpose of improving the life of these patients with TAVR would be defeated. It would be interesting to know how this study will affect the practice guidelines for such patients in the future. Will it be mandatory to correct all such MR in patients with aortic stenosis selected for TAVR? Should these patients be offered high-risk surgical procedures? Or is there an alternate hybrid procedure with limited access approaches? Is the transapical approach useful in correcting both lesions? This article will generate interest in finding an appropriate solution to such complex problems in the future. Transcatheter Aortic Valve Replacement in Patients With Aortic Stenosis and Mitral RegurgitationThe Annals of Thoracic SurgeryVol. 104Issue 6PreviewMany patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis also have significant mitral regurgitation (MR). We sought to understand the association of concomitant MR with TAVR clinical outcomes, as well changes in MR after TAVR. Full-Text PDF