Prognosis of functional mitral regurgitation after aortic valve replacement for pure severe aortic stenosis

Combined Significant Aortic Stenosis and Mitral Regurgitation: Challenges in Timing and Type of Intervention

In this narrative review, we aim to summarize the literature surrounding the assessment and management of the common, yet understudied combination of aortic stenosis (AS) and mitral regurgitation (MR), the components of which are complexly inter-related and interdependent from diagnostic, prognostic, and therapeutic perspectives. The hemodynamic interdependency of AS and MR confounds the assessment of the severity of each valve disease, thus underscoring the importance of a multimodal approach integrating valvular and extravalvular indicators of severity. A large body of literature suggests that baseline MR is associated with reduced survival post aortic valve (AV) intervention and that regression of MR post-AV intervention confers a mortality benefit. Functional MR is more likely to regress after AV intervention than primary MR. The respective natural courses of the 2 valve diseases are not synchronized; therefore, significant AS and MR at or above the respective threshold for intervention might not coincide. Surgery is primarily a 1-stop-shop procedure because of a considerable perioperative risk of repeat interventions, whereas transcatheter treatment modalities allow for a more tailored timing of intervention with reassessment of concomitant MR after AV replacement and a potential staged intervention in the absence of MR regression. In summary, AS and MR, when combined, are interlaced into a complex hemodynamic, diagnostic, and prognostic synergy, with important therapeutic implications. Contemporary approaches should consider stepwise intervention by exploiting the advantage of transcatheter options. However, evidence is needed to demonstrate the efficacy of different timing and therapeutic options.

The fate of concomitant mild mitral regurgitation in aortic insufficiency: A neglected subject

Objectives

Mitral regurgitation (MR) is commonly experienced by patients with aortic insufficiency (AI), and in its mild form, it is considered benign. However, the progression of concomitant mild regurgitation after the aortic valve surgery (AVS) for AI is poorly characterized. The current study aimed to define the long-term outcomes of MR after surgery and identify the risk factors involved in deterioration.

Methods

Patients presenting with moderate/severe AI and concomitant mild MR (n = 347) between January 2013 and December 2021 were enrolled. MR grade was assessed by transthoracic echocardiography during the follow-up, and deterioration is defined as an increase in grade to moderate or severe MR from the previous follow-up echocardiography. Analysis of risk factors for early mortality, MR deterioration, and long-term mortality was performed.

Results

A total of 278 patients (84.8%) among 328 survivors had at least one follow-up echocardiography, and complete follow-up occurred for 316 patients (96.3%). Mild MR improved to trivial or none in 194 patients (69.8%), progressed to persistent mild MR for 74 patients (26.6%), and deteriorated for 10 patients (3.6%). Preoperative atrial fibrillation [odds ratio (OR), 23.09; 95% confidence interval (CI), 4.35-122.54] and rheumatic AI (OR, 11.61; 95% CI, 1.26-106.85) were shown to be independent risk factors for MR deterioration by generalized linear mixed analysis.

Conclusion

Progression of concomitant mild MR is rare in patients with AI after AVS. However, rheumatic AI and preoperative atrial fibrillation increase the probability of MR deterioration. Careful follow-up for this cohort of patients is recommended.

Prognostic relevance of mitral and tricuspid regurgitation after transcatheter aortic valve implantation: Impact of follow-up time point for decision-making

Background

In patients with aortic stenosis treated by transcatheter aortic valve implantation (TAVI), mitral and tricuspid regurgitation (MR and TR) at baseline and after TAVI are likely to be of prognostic relevance, and questions such as whether and when treatment further improves prognosis in these patients arise.

Aims

Against that background, the purpose of this study was to analyze a variety of clinical characteristics including MR and TR with respect to their potential value as predictors of 2-year mortality after TAVI.

Methods

A cohort of 445 typical TAVI patients was available for the study and clinical characteristics were evaluated baseline, 6 to 8 weeks as well as 6 months after TAVI.

Results

In 39% of the patients relevant (moderate or severe) MR and in 32% of the patients relevant (moderate or severe) TR could be detected at baseline. The rates were 27% for MR (p = 0.001, compared to baseline) and 35% for TR (p = n.s., compared to baseline) at the 6- to 8-week follow-up. After 6 months, relevant MR was observable in 28% (p = 0.036, compared to baseline) and relevant TR in 34% (p = n.s., compared to baseline) of the patients. As predictors of 2-year mortality, a multivariate analysis identified the following parameters for the different time points: sex, age, AS entity, atrial fibrillation, renal function, relevant TR, systolic pulmonary artery pressure (PAPsys), and 6-min walk distance at baseline; clinical frailty scale and PAPsys 6-8 weeks after TAVI and BNP and relevant MR 6 months after TAVI. There was a significantly worse 2-year survival in patients with relevant TR at baseline (68.4% vs. 82.6%, p < 0.001; whole population, n = 445) and in patients with relevant MR at 6 months (87.9% vs. 95.2%, p = 0.042; landmark analysis: n = 235).

Conclusion

This real-life study demonstrated the prognostic relevance of repeated evaluation of MR and TR before and after TAVI. Choosing the right time point for treatment is a remaining clinical challenge, which should be further addressed in randomized trials.