Perioperative Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement with Concomitant Mitral Regurgitation: A Meta-Analysis

Transcatheter aortic valve replacement (TAVR) is widely performed in high-risk patients with severe aortic stenosis. However, the effects of baseline concomitant mitral regurgitation (MR) on perioperative outcomes remain unclear. This study evaluated the impact of concomitant MR severity on short-term TAVR outcomes. A systematic search of 6 electronic databases was conducted. Studies that stratified patients based on MR severity (MR ≥2 vs. <2 or MR ≥3 vs. <3) and reported perioperative outcomes, including short-term mortality, in-hospital mortality, acute kidney injury (AKI), pacemaker implantation, bleeding, vascular complications, and MR improvement (up to 1 week and 1 month) were eligible. Data from 26 studies (32,453 patients) demonstrated that patients with baseline moderate-to-severe MR (MR ≥2) had a 49% (95% confidence interval (CI), 1.32-1.70) increased risk of short-term mortality, a 41% (95% CI, 1.22-1.63) higher risk of in-hospital mortality, and a 38% (95% CI, 1.17-1.62) higher risk of AKI than those with none-to-mild MR (MR<2). Patients with an MR ≥3 had an even greater 72% (95% CI, 1.37-2.16) increase in short-term mortality. No significant differences were observed in pacemaker implantation, bleeding, or vascular complications between groups. Additionally, after TAVR, MR improved in 36% of patients by at least 1 grade within 1 week, increasing to 44% by 1 month. In TAVR patients, MR ≥2 was associated with significantly higher early mortality and AKI risk, underscoring the need for a comprehensive perioperative risk assessment. Future studies should examine the differential impact of functional and degenerative MR.

Comparing moderate-severe and severe mitral regurgitation in transcatheter aortic valve replacement on 1-year survival: insights from a Japanese Nationwide Registry

This study aims to compare 1-year outcomes after transcatheter aortic valve replacement (TAVR) between patients with moderate-severe MR and severe MR preoperatively using the Japan Transcatheter Valve Therapy (J-TVT) registry. Patients undergoing TAVR for aortic stenosis between August 2013 and December 2019 with preoperative mitral regurgitation of moderate-severe (group MR3) or severe (group MR4) were included. Patients with a history of valve surgery and dialysis patients were excluded. A total of 2017 patients were included, and 1-year follow-up data were obtained from the registry (follow-up rate 98.5%). Propensity-score matching between MR3 and MR4 groups was performed. All-cause mortality and the composite outcome of death and/or heart failure events were compared. Crude data showed that 1-year survival was significantly higher in the MR 3 (89.8%) than MR 4 (84.7%) groups, and freedom from 1-year mortality and heart failure events was also higher in the MR 3 (87.1%) than MR 4 (80.5%) groups (p = 0.0001). After propensity-score matching, 452 cases (226 cases each in MR 3 group and MR 4 group) were extracted. Cox regression model showed no statistical difference in the 1-year survival rate between MR 3 group (84.5%) and MR 4 group (85.5%) (p = 0.84), nor in freedom from 1-year death and/or heart failure events between MR 3 group (80.2%) and MR 4 group (81.6%) (p = 0.72). The 1-year survival rate and freedom from death and/or heart failure events were found to be similar between patients undergoing TAVR with MR grade 3 and MR grade 4.

Transfemoral Aortic Valve Implantation in Patients With Severe Aortic Stenosis and Coexisting Mitral Valve Regurgitation

INTRODUCTION

Severe aortic stenosis with coexisting mitral regurgitation (MR) of various severity is a common finding. The goal of our study was to evaluate the relation between transcatheter transfemoral aortic valve implantation (TAVI) on coexisting MR and compare the outcome in MR improvement and nonimprovement groups.

METHODS

We retrospectively analyzed 252 patients who underwent TAVI with associated at least moderate MR between January 2018 and December 2020. Effect of changes in MR grade at discharge and 6-12 mo follow-up were compared.

RESULTS

Echocardiography was performed at discharge in 245 patients and at follow-up in 154 patients. MR improvement was seen in 60.8% patients and nonimprovement in 39.2%. Overall survival was significantly higher in the MR improvement group (P = 0.020). There was a statistically significant effect on MR grade with a significant increase in the proportion of patients with mild MR at follow-up compared to discharge (58.4% versus 38.3%, P < 0.001). A similar positive effect was seen on left ventricular ejection fraction (LVEF) at follow-up compared to discharge (P < 0.001). LVEF in the MR improvement group was significantly higher at follow-up versus discharge (P < 0.001), but there was no statistically significant change in LVEF in the nonimprovement group at follow-up versus discharge (P < 0.722).

CONCLUSIONS

TAVI in severe aortic stenosis with coexisting significant mitral valve regurgitation decreases MR severity in more than 60% of patients and improved LVEF as well as mortality.

Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.

Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

BACKGROUND

Mitral regurgitation (MR) is commonly seen in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). But the long-term implications of MR in AS are unknown.

AIM

To investigate MR's impact on survival of patients undergoing surgical AVR for severe AS.

METHODS

Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003, 287 underwent AVR forming the study cohort. They were followed up to death or till the end of 2019. Chart reviews were performed for clinical, echocardiographic, and therapeutic data. MR was graded on a 1-4 scale. Mortality data was obtained from chart review and the Social Security Death Index. Survival was analyzed as a function of degree of MR.

RESULTS

The mean age of the severe AS patients who had AVR (n = 287) was 72 ± 13 years, 46% women. Over up to 26 years of follow up, there were 201 (70%) deaths, giving deep insights into the determinants of survival of severe AS who had AVR. The 5, 10 and 20 years survival rates were 75%, 45% and 25% respectively. Presence of MR was associated with higher mortality in a graded fashion (P = 0.0003). MR was significantly associated with lower left ventricular (LV) ejection fraction and larger LV size. Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size. By Cox regression, MR, lower ejection fraction (EF) and larger LV end-systolic dimension were independent predictors of higher mortality (χ2 = 33.2).

CONCLUSION

Presence of greater than 2+ MR in patients with severe AS is independently associated with reduced survival in surgically managed patients, an effect incremental to reduced EF and larger LV size. We suggest that aortic valve intervention should be considered in severe AS patients when > 2+ MR occurs irrespective of EF or symptoms.

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.

Evaluating the effect of multivalvular disease on mortality after transcatheter aortic valve replacement for aortic stenosis: a meta-analysis and systematic review

Aims: To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Methods: Patients undergoing TAVR for aortic stenosis with covariate-adjusted risk of mortality associated with concomitant valve disease (mitral regurgitation [MR], mitral stenosis [MS] or tricuspid regurgitation [TR]) were included. Results: Moderate-to-severe MR was associated with increased mortality at 30 days (hazard ratio [HR]: 1.60; 95% CI: 1.11-2.30; p = 0.01) and 1 year (HR: 1.87; 95% CI: 1.22-2.87; p = 0.004). The presence of all-grade MS did not impact 30-day or 1-year mortality (HR, 30 days: 1.60; 95% CI: 0.71-3.63; p = 0.26; and HR, 1 year: 1.90; 95% CI: 0.98-3.69; p = 0.06); however, an increased risk of 1-year mortality (HR: 1.67; 95% CI: 1.03-2.70; p = 0.04) was observed with severe MS compared with no MS. Moderate-to-severe TR had a higher risk of all-cause mortality at 1 year (HR: 1.49; 95% CI: 1.24-1.78; p < 0.001) compared with no or mild TR. Conclusion: Moderate-to-severe MR or TR, and severe MS, significantly increase mid-term mortality after TAVR.

Mixed-Valve Disease: Management of Patients with Aortic Stenosis and Mitral Regurgitation: Thresholds for Surgery Versus Percutaneous Therapies

Significant mitral regurgitation (MR), frequently seen in the presence of severe aortic stenosis (AS), results in an association that negatively affects prognosis and imposes particular challenges for both the assessment of the severity of valvular lesions and decisions regarding treatment allocation. This article reviews the available literature with regards to the assessment of MR and AS in the presence of both; surgical management and results in patients with concomitant AS and MR; the effect of MR on outcomes in patients undergoing transcatheter aortic valve replacement; the effect of transcatheter aortic valve replacement on MR severity; and percutaneous treatment for MR after transcatheter aortic valve implantation. The authors aim to provide assistance in the decision-making process to treat patients with either a higher-risk double-valve procedure or a simpler, but perhaps incomplete, single-valve option.