Adaptive development of concomitant secondary mitral and tricuspid regurgitation after transcatheter aortic valve replacement

Abstract

Aims Concomitant secondary atrioventricular regurgitation is frequent in patients with severe aortic stenosis scheduled for transcatheter aortic valve replacement (TAVR). The future implications of leaving associated valve lesions untreated after TAVR remain unknown. Aim of the present study was to characterize the evolution of concomitant secondary atrioventricular regurgitations and to evaluate their impact on long-term prognosis. Methods and results We prospectively enrolled 429 consecutive TAVR patients. All patients underwent comprehensive clinical, laboratory, and echocardiographic assessments prior to TAVR, at discharge, and yearly thereafter. All-cause mortality was chosen as primary study endpoint. At baseline, severe concomitant secondary mitral regurgitation (sMR) was present in 54 (13%) and severe concomitant secondary tricuspid regurgitation (sTR) in 75 patients (17%). After TAVR 59% of patients with severe sMR at baseline experienced sMR regression, whereas analogously sTR regressed in 43% of patients with severe sTR. Persistence of sTR and sMR were associated with excess mortality after adjustment for our bootstrap-selected confounder model with an adjusted HR of 2.44 (95% CI 1.15–5.20, P = 0.021) for sMR and of 2.09 (95% CI 1.20–3.66, P = 0.01) for sTR. Patients showing regression of atrioventricular regurgitation exhibited survival rates indistinguishable to those seen in patients without concomitant atrioventricular regurgitation (sMR: P = 0.83; sTR: P = 0.74). Conclusion Concomitant secondary atrioventricular regurgitation in patients with severe AS is a highly dynamic process with up to half of all patients showing regression of associated valvular regurgitation after TAVR and subsequent favourable post-interventional outcome. Persistent atrioventricular regurgitation is a major determinant of unfavourable outcome after TAVR and proposes a window of early sequel intervention.

Potential Candidates for Transcatheter Tricuspid Valve Intervention After Transcatheter Aortic Valve Replacement

“…In patients with severe AS, TR is, at least in part, a consequence of increased afterload due to AS (21). Thus, clinically relevant TR has been shown to improve in 15% to 60% of patients undergoing TAVR (4,5,9,10,22). In contrast, owing to the dynamic and load dependent nature of TR, progression of TR after TAVR has been reported in 4%-11% of patients with nonsignificant TR at baseline (4,5,23).…”

“…In contrast, owing to the dynamic and load dependent nature of TR, progression of TR after TAVR has been reported in 4%-11% of patients with nonsignificant TR at baseline (4,5,23). Previous studies suggested that persistent or worsening of moderate or greater TR was associated with an increased risk of mortality (6,9,10,22,23). Consistent with these studies, more than half of patients with significant baseline TR had an improvement of at least one grade after TAVR, while a small proportion of patients (5% to 7%) with baseline <massive TR had a progression in the TR severity after TAVR in the present study.…”

TAVI in patients with low-flow low-gradient aortic stenosis–short-term and long-term outcomes

“…The rate of atrioventricular valve regurgitation was higher among LFLG compared to HG patients, as expected. This is relevant because persistent MR or TR after TAVI is associated with a two-fold mortality increase, as recently reported by Winter et al [ 19 ]. To what extent this is applicable particularly to LFLG patients remains to be elucidated.…”

The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention

“…In addition, many other variables can predict improvement in secondary or mixed MR: dilated LV and a decreased ejection fraction (indicating a greater propensity for reverse remodeling), LV dyssynchrony due to new left bundle branch block, right ventricular pacing or ischemic wall motion abnormalities, and a significant decrease in the transaortic pressure gradient (including a high preoperative transvalvular pressure gradient) [59]. Moreover, secondary atrioventricular MR is common in patients with severe AS undergoing AVR [60]. Therefore, it is not surprising that the occurrence of atrial fibrillation, pulmonary hypertension, and atrial and/or mitral annulus dilatation, both of which are associated with higher chronic MR repercussions, has been linked to more limited improvement in MR [13].…”