Mitral regurgitation in patients undergoing transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: Insights from PARTNER 2 Valve-in-Valve Registry

The Impact of Concomitant Mitral Regurgitation on Echocardiography Parameters After TransCatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

BACKGROUND

Mitral regurgitation (MR) commonly coexists with aortic stenosis (AS) and is a potential risk factor influencing outcomes following transcatheter aortic valve replacement (TAVR). This meta-analysis aimed to evaluate the mean changes in key echocardiographic parameters before and after TAVR and to compare these changes between patients with moderate-to-severe MR (MR ≥ 2) and those with none-to-mild MR (MR < 2).

METHODS

A comprehensive literature search was conducted using six electronic databases. We included studies that evaluated patients undergoing TAVR, classified them based on baseline MR grade ≥ 2 (moderate/severe MR) or MR grade < 2 (none/mild MR), and reported the mean difference (MD) in echocardiographic parameters before and after TAVR in both groups. The primary outcomes included changes in ejection fraction (EF), LV end-diastolic volume (LVEDV) index, LV end-systolic volume (LVESV) index, LV end-diastolic diameter (LVEDD), LV end-systolic diameter (LVESD), aortic valve area (AVA), and the mean aortic gradient. Pooled MDs were analyzed using a random-effects model.

RESULTS

Thirteen studies with 7163 patients were included, of which 2376 had an MR ≥ 2. The MR < 2 and MR ≥ 2 groups experienced significant improvements in AVA and reductions in mean aortic gradient, LVEDV index, LVESV index, LVEDD, and LVESD. Compared to MR < 2 patients, those with MR ≥ 2 exhibited significantly greater improvements in EF (MD = 2.03; 95% CI: 0.81, 3.24), LVEDV index (MD = -5.55; 95% CI: -7.85, -3.26), LVESV index (MD = -5.43; 95% CI: -7.28, -3.58), LVESD (MD = -2.23; 95% CI: -3.71, -0.26), and mean aortic gradient (MD = 1.43; 95% CI: 0.79, 2.07). However, the changes in LVEDD and AVA were not significantly different between the groups.

CONCLUSIONS

These findings suggest that patients with moderate-to-severe baseline MR before TAVR showed greater pronounced improvements in specific echocardiographic parameters related to LV function and geometry, particularly in LVEF, LVEDV index, LVESV index, and LVESD, compared to those with none-to-mild MR. Future studies should focus on stratifying outcomes according to MR etiology and using advanced imaging techniques to delineate better the mechanisms underlying these improvements.

Impact of concomitant mitral regurgitation during transcatheter aortic valve replacement on 1-year survival outcomes

BACKGROUND

We investigated the influence of concomitant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation on the 1-year outcome using Japan Transcatheter Valve Therapy (J-TVT) registry data.

METHODS

The patients who underwent the transcatheter aortic valve implantation for aortic stenosis performed from August 2013 to December 2019 in Japan were included. History of previous valve surgery and dialysis patients were excluded. A total of 24,979 patients were included, and 1-year follow-up data were obtained from the registry (follow-up rate 98.5 %). Propensity-score matching, using multivariable logistic regression and 1:1 matching without replacement, was performed between the patients with grade 3-4 MR (MR 3-4 group) and those with grade 0-2 MR (MR 0-2 group). All-cause death and the composite outcome of death and/or heart failure events were compared.

RESULTS

After propensity score matching, 3920 cases (1960 cases each in MR 0-2 group and MR 3-4 group) were extracted. The procedure success rate was 96.4 % in MR 0-2 and 96.0 % in MR 3-4 group (p = 0.56) and the surgical conversion rate was 0.7 % in MR 0-2 group and 0.8 % in MR 3-4 group (p = 0.58). Cox regression model showed no statistical difference in 1-year survival rate between MR 0-2 group (89.4 %) and MR 3-4 group (89.6 %) (p = 0.80). However, freedom from 1-year death and/or heart failure event was lower in MR 3-4 (86.3 %) than in MR 0-2 group (88.9 %) (p = 0.01). This trend was also found in the subgroup of New York Heart Association (NYHA) class 1-2 but not in the subgroup of NYHA class 3-4.

CONCLUSIONS

One-year survival rate was not different between groups but freedom from death and/or heart failure events was lower in patients with preoperative MR grade 3-4 than in patients with preoperative MR grade 0-2 after transcatheter aortic valve replacement.

Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation

INTRODUCTION

Significant mitral regurgitation (MR) frequently coexists in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). These patients have worse clinical outcomes than those with non-significant MR, especially if MR persists after treatment of the aortic stenosis. The optimal treatment approach for this challenging high-risk population is not well defined.

AREAS COVERED

This review aims to present the current literature on concomitant significant MR in the TAVR population, and to provide a comprehensive algorithmic approach for clinical decision-making in this challenging cohort of patients.

EXPERT OPINION

Concomitant mitral and aortic valve disease is a complex clinical entity. An exhaustive and comprehensive assessment of patient's clinical characteristics and mitral valve anatomy and function is required in order to assess the surgical risk, predict the MR response after AVR and evaluate the feasibility of percutaneous MV treatment if necessary. Further developments in transcatheter techniques will expand the indications for double valve treatment in operable and inoperable patients with concomitant significant MR and aortic stenosis.

Predictors and Outcome Impact of Mitral Regurgitation in Transcatheter Aortic Valve Replacement

BACKGROUND/PURPOSE

Several studies have reported that mitral regurgitation (MR) can improve following transcatheter aortic valve replacement (TAVR) alone using earlier-generation valves. The purpose of this study was to determine the predictors and short-term outcome impact of MR in patients undergoing TAVR using all generation valves across all risk groups.

METHODS/MATERIALS

In this retrospective, study from 2012 to 2020, we reviewed data on 1822 low-, intermediate-, and high-risk patients who underwent TAVR. Included were 1266 patients with baseline MR who underwent transfemoral TAVR. Our primary outcome was persistence or worsening of baseline MR post-TAVR. Additional endpoints included an inpatient composite (intensive care unit length of stay >24 h, post-TAVR length of stay >2 days, and inpatient death), 30-day composite (30-day death or readmission), and 1-year composite (1-year death or readmission).

RESULTS

Of the 1266 patients included, 665 had significant baseline MR (≥moderate), which improved in 79.4% of patients (n=528). Female patients, those with lower body mass indices, and those with higher right ventricular systolic pressures were more likely to have persistence or worsening of baseline MR. Patients whose baseline MR persisted or worsened, had higher rates (80.3% vs. 77.3%, p=0.0019) of our inpatient composite, higher rates (15.3% vs. 10.0%, p=0.0389) of our 30-day composite, and higher rates (36.7% vs. 26.8%, p=0.0107) of our 1-year composite when compared to patients whose baseline MR improved post-TAVR.

CONCLUSIONS

Our study identifies clinical characteristics, which help identify patients who may require closer post-procedural follow-up and warrant possible staged mitral valve intervention post-TAVR across all risk groups.

Balloon-expandable versus self-expanding transcatheter aortic valve replacement for bioprosthetic dysfunction: A systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve-in-valve (VIV) procedure is a safe alternative to conventional reoperation for bioprosthetic dysfunction. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the 2 major types of devices used. Evidence regarding the comparison of the 2 valves remains scarce.

METHODS

A systematic review and meta-analysis was conducted to compare the outcomes of BEV and SEV in transcatheter VIV for aortic bioprostheses dysfunction. A computerized search of Medline, PubMed, Embase, and Cochrane databases was performed. English-language journal articles reporting SEV or BEV outcomes of at least 10 patients were included.

RESULTS

In total, 27 studies were included, with 2,269 and 1,671 patients in the BEV and SEV groups, respectively. Rates of 30-day mortality and stroke did not differ significantly between the 2 groups. However, BEV was associated with significantly lower rates of postprocedural permanent pacemaker implantation (3.8% vs. 12%; P < 0.001). Regarding echocardiographic parameters, SEV was associated with larger postprocedural effective orifice area at 30 days (1.53 cm2 vs. 1.23 cm2; P < 0.001) and 1 year (1.55 cm2 vs. 1.22 cm2; P < 0.001).

CONCLUSIONS

For patients who underwent transcatheter aortic VIV, SEV was associated with larger postprocedural effective orifice area but higher rates of permanent pacemaker implantation. These findings provide valuable information for optimizing device selection for transcatheter aortic VIV.