Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement☆
Introduction
Aortic stenosis and mitral regurgitation (MR) are the most common valve diseases in Europe and the United States [1,2]. Approximately a fifth of patients who undergo transcatheter aortic valve replacement (TAVR) to treat aortic stenosis also have concomitant moderate or severe MR [3].
Recent meta-analyses show that baseline MR increases 30-day and 1-year mortality after TAVR [[4], [5], [6]], but less is known about the prognostic impact of baseline MR beyond the first post-procedural year. Furthermore, although residual MR has been shown to confer an increased mortality rate after TAVR [5], the clinical effect of MR reduction or MR worsening is not known. We therefore assessed the long-term impact of pre-TAVR MR, and MR change from baseline to first available post-procedural echocardiogram in TAVR recipients in the Swedish TAVR Registry.
Section snippets
Methods
Between the 1st of January 2008 and 31st of April 2015, 1739 patients underwent TAVR for treatment of symptomatic severe aortic stenosis at eight Swedish centers. The balloon-expandable Cribier-Edwards, Edwards SAPIEN, SAPIEN XT or Sapien 3 (Edwards Lifesciences, Irvine, California) was used in 735 cases (43%); the self-expandable Medtronic CoreValve (Medtronic, Minneapolis, Minnesota) in 886 (52%); and the Boston Lotus Valve (Boston Scientific, Marlborough, Massachusetts) was used in 75 cases
Results
A total of 1712 consecutive patients were included in the analysis. At baseline MR was mild or less in 1404 patients (82%), and moderate or severe in 308 patients (18%). Of those with moderate or severe MR, 148 (48%) had organic MR and 158 (52%) had functional MR, data was missing for two subjects. As shown in Table 1, moderate or severe MR was associated with female sex, older age, lower BMI, lower incidence of recent MI, atrial fibrillation, higher degree of NYHA class, lower LVEF, lower AVA
Discussion
In the present national multicenter registry-based study, concomitant moderate or severe baseline MR was present in 18% of TAVR recipients with severe aortic stenosis. As expected, moderate or severe MR at baseline was associated with lower calculated aortic valve area, pulmonary hypertension, the presence of atrial fibrillation and lower LV ejection fraction. When adjusting for these factors, and others, the presence of double valve disease at baseline was associated with greater mortality
Study limitations
The main limitation of this study stems from its register-based nature with a selection of cases amenable to catheter-based therapy. Also, data is reported by participating centers without an independent adjudication committee, except for mortality, which was extracted from the National Civil Registry with 100% capture. The absence of a centralized imaging core lab may have led to non-differential misclassification of echocardiographic parameters. Although data on MR degree after TAVR are based
Conclusions
Concomitant moderate or severe mitral regurgitation at baseline affects roughly a fifth of TAVR recipients with severe aortic stenosis, and is associated with increased all-cause mortality up to 5 years after TAVR. The evolution of MR after TAVR appears to determine whether the mortality risk carried by baseline MR is either reversed by an improvement in MR severity; or accentuated by worsening MR; or remains in moderate/severe post-TAVR MR. Hence, the change in mitral regurgitation severity
Declaration of Competing Interest
Dr. Feldt has received consulting fees from Orion Pharma and Pfizer. Rodney De Palma, Henrik Bjursten, Petur Petursson, Niels Erik Nielsen, Thomas Kellerth, and Johan Nilsson report no relationships that could be construed as a conflict of interest. Dr. Jönsson has served as a proctor for Medtronic. Dr. Rück has served as a proctor for Boston Scientific and has received consulting fees from Medtronic and Edwards. Dr. Settergren has served as a proctor for Abbott, Boston Scientific and has
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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.