Elsevier

International Journal of Cardiology

Volume 294, 1 November 2019, Pages 32-36
International Journal of Cardiology

Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement

https://doi.org/10.1016/j.ijcard.2019.07.075Get rights and content

Highlights

  • Mitral regurgitation increases 5-year mortality in TAVR.

  • Improvement of MR after TAVR neutralizes risk of baseline MR.

  • Worsening mitral regurgitation severity confers highest risk of all cause death.

  • Paravalvular leak related to both MR worsening and absence of MR improvement

  • Self expanding valve prostheses linked to MR worsening after adjusting for PVL

Abstract

Background

The impact of a change in mitral regurgitation (MR) following TAVR is unknown. We studied the impact of baseline MR and early post-procedural change in MR on survival following TAVR.

Methods

The SWEDEHEART registry included all TAVRs performed in Sweden. Patients were dichotomized into no/mild and moderate/severe MR groups. Vital status, echocardiographic data at baseline and within 7 days after TAVR were analyzed.

Results

1712 patients were included. 1404 (82%) had no/mild MR and 308 (18%) had moderate/severe MR. Baseline moderate/severe MR conferred a higher mortality rate at 5-year follow-up (adjusted HR 1.29, CI 1.01–1.65, p = 0.04). Using persistent ≤mild MR as the reference, when moderate/severe MR persisted or if MR worsened from ≤mild at baseline to moderate/severe after TAVR, higher 5-year mortality rates were seen (adjusted HR 1.66, CI 1.17–2.34, p = 0.04; adjusted HR 1.97, CI 1.29–3.00, p = 0.002, respectively). If baseline moderate/severe MR improved to ≤mild after TAVR no excess mortality was seen (HR 1.09, CI 0.75–1.58, p = 0.67). Paravalvular aortic regurgitation (PVL) was inversely associated with MR improvement after TAVR (OR 0.4, 95%: CI 0.17–0.94; p = 0.034). Atrial fibrillation (OR 2.1, 95% CI: 1.27–3.39, p = 0.004), self-expanding valve (OR 3.8, 95% CI: 2.08–7.14, p < 0.0001), and PVL (4.3, 95% CI 2.32–7.78. p < 0.0001) were associated with MR worsening.

Conclusions

Moderate/severe baseline MR in patients undergoing TAVR is associated with a mortality increase during 5 years of follow-up. This risk is offset if MR improves to ≤mild, whereas worsening of MR after TAVR is associated with a 2-fold mortality increase.

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

References (31)

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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.

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