Transcatheter aortic valve implantation for combined aortic and mitral stenoses: Insights from the OCEAN-TAVI Registry.

Abstract

Mitral stenosis (MS) occasionally coexists with aortic stenosis (AS). Limited data are available regarding the functional class and clinical outcomes of patients who undergo transcatheter aortic valve implantation (TAVI) for combined AS and MS. This study compared the clinical outcomes in patients with and without MS who underwent TAVI for severe AS and assessed the impact of mitral annulus calcification (MAC) severity, transmitral gradient (TMG) and mitral valve area (MVA) on outcomes in patients with combined AS and MS. We investigated patients in the OCEAN-TAVI registry who underwent TAVI. MS was defined as an MVA≤1.5cm2 or TMG≥5mmHg. The composite of all-cause death and admission for heart failure was compared between patients with and without MS. The impact of MAC, TMG and MVA on outcomes was assessed in patients with combined AS and MS. We identified 106 patients with MS (MAC 84%; TMG 6.4±2.6mmHg; MVA 1.10±0.31cm2) and 6570 without MS as controls. The MS group was older (85±5 vs. 84±5years, P=0.033), more of women (85 vs. 67%, P<0.01), and had a higher risk of surgery (the Society of Thoracic Surgeons Mortality Score 8.7±5.1 vs. 7.6±5.9, P=0.047) than the controls. In the MS group, the New York Heart Association Functional Class was 3 or 4 in 56% of the patients at baseline and 6% at 1year after TAVI. Thirty-day mortality (2.8% vs. 1.3%, P=0.18) and early composite outcomes (17% vs. 15%, P=0.56) were comparable between patients with and without MS. During a median follow-up of 2.1years, the presence of MS was associated with a higher incidence of adverse events compared with controls (adjusted hazard ratio [HR] 1.84; 95% confidence interval [CI] 1.34-2.51, P<0.01), even on propensity score matched analysis (adjusted HR 1.91; 95% CI 1.14-3.22, P<0.01). Moderate or severe MAC contributed to increased risk of adverse events in patients with MS (adjusted HR 2.89; 95% CI 1.20-6.99, P=0.018), but TMG and MVA did not. In patients undergoing TAVI for severe AS, those with moderate or severe MS experienced worse outcomes after TAVI compared with those without MS. Patients with combined AS and MS sustained symptom improvement at 1-year post-TAVI. MAC severity was a useful predictor of adverse events compared with MS haemodynamics such as TMG and MVA in patients with combined AS and MS.