Abstract
ObjectiveThe 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).BackgroundConcomitant MR is a frequent finding in patients with severe aortic stenosis but usually left untreated at the time of TAVR.MethodsMitral 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.Results15.2% 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.ConclusionUnresolved 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.Graphic abstractFactors associated with MR persistence or regression after TAVR
Highlights
Relevant concomitant mitral regurgitation (MR) is present in up to one-third of patients with severe aortic stenosis [1,2,3,4]
836 consecutive patients underwent transcatheter aortic valve replacement (TAVR) for severe native aortic stenosis between January 2013 and August 2016 at Cologne University Heart Center. 59 patients were excluded due to missing TTE data at the time of analysis (n = 48), previous mitral valve surgery (n = 3) or subsequent transcatheter mitral valve repair (n = 8). 777 patients with complete baseline TTE data were available for outcome analyses, and 677 with baseline and discharge TTE data were used for the analysis of MR evolution after TAVR (Supplementary Fig. 1)
84.8% of patients presented with MR ≤ 2 + (13.6% no MR, 48.3% mild MR, 22.9% mild to moderate MR), and 15.2% with MR ≥ 3 + (11.2% moderate to severe MR, 4.0% severe MR)
Summary
Relevant concomitant mitral regurgitation (MR) is present in up to one-third of patients with severe aortic stenosis [1,2,3,4]. Combined aortic and mitral valve surgery yielded good long term functional results at the cost of a substantially increased operative mortality [7,8,9]. MR remains unchanged or even worsens in some patients and predictors for MR improvement are not well defined [2, 3] This is important since significant baseline or residual MR is associated with an increased mortality after TAVR [3, 4]. It is unclear, (a) whether MR improvement after TAVR impacts on survival and (b) whether echocardiographic parameters can predict the resolution and persistence of MR in this patient population, respectively.
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