Effect of Aortic Valve Replacement, for Aortic Stenosis, on Concomitant Mitral Valve Regurgitation

Abstract

A AB BS S T TR RA AC CT T O Ob bj je ec ct ti iv ve e: : Mild-to-moderate mitral regurgitation (MR) often coexists with severe aortic stenosis and has been reported to be presented in up to 2/3 patients requiring aortic valve replacement (AVR). MR in patients with aortic stenosis is often functional in nature although organic mitral disease may coexist. Increased afterload and left ventricular remodeling have been implicated to explain the functional MR in patients with aortic valve stenosis. Furthermore, remodeling observed after AVR may impact the outcome of MR postoperatively. However, the clinical outcome of persistent MR after AVR is uninvestigated. On the other hand, concomitant replacement of the aortic and mitral valves is associated with an increased morbidity and mortality compared to an isolated AVR. This study aims to assess the change in MR severity following AVR for severe AS and to determine the factors associated with the MR improvement. M Ma at te er ri ia al l a an nd d M Me et th ho od ds s: : The clinical and surgical characteristics were compared in a cohort of 149 consecutive patients who underwent isolated AVR in Aleppo University Hospital for cardiac surgery. R Re es su ul lt ts s: : Non-severe functional mitral valve regurgitation was detected prior to surgery in 25.5% of the patients. These patients were older (p = 0.007), more often had ventricular dysfunction (p = 0.02) and pulmonary hypertension (p = 0.04), and had been admitted more frequently for heart failure (0.008), with fewer of them conserving sinus rhythm (p = 0.003). In addition, the pre-surgery existence of MR was associated with greater morbidity and mortality (5.2% vs. 3.7%; p = 0.025). The MR disappeared or improved prior to hospital discharge in 56.2% and 15.6%, respectively. Independent factors predicting this improvement were the presence of coronary lesions (OR 3.74, p = 0.03), and the absence of diabetes (OR 0.28, p = 0.005) as well as pulmonary hypertension (OR 0.34, p = 0.01). C Co on nc cl lu u--s si io on n: : In this study, MR decreased or disappeared in a high percentage of patients after AVR surgery. Independent factors predicting this improvement included the presence of prior coronary lesions, although the improvement is influenced by the diabetic status of the patient, as well as pulmonary hypertension. K Ke ey y W Wo or rd ds s: : Cardiac valve annuloplasty; cardiomegaly; cardiac resynchronization therapy; vascular stiffness; venous valves; thoracic surgery Ö ÖZ ZE ET T A Am ma aç ç: : Hafiften ılımlıya mitral regürjitasyonda (MR) genellikle şiddetli aort stenozu (AS) birlikte bulunur ve başvuran hastaların 2/3'ünden fazlasında aort kapağı replasmanı (AVR) gerektiği bildirilmiştir. Aort stenozlu MR olguları sıklıkla işlevsel yapıda olmalarına rağmen, organik mitral kapak hastalığı eş zamanlı bulunabilir. Aortik kapak stenozlu fonksiyonel MR hastalarında artmış ard yük ve sol ventrikülün yeniden şekillenmesi söz konusudur. Hatta, AVR sonrası gözlenen bu yeniden şekillenme, postop MR sürecini etkileyebilir....

Concomitant Mitral Regurgitation in Patients Undergoing Surgical Aortic Valve Replacement for Aortic Stenosis: A Systematic Review

“… 10 , 19 , 20) Other factors included the presence of coronary artery disease, lower left ventricular ejection fraction (LVEF) and increased left atrial size. 2 , 21) Independent factors associated with persistent MR post AVR were analyzed in 3 studies and 2 of these identified significant comorbid factors, which included elevated right ventricular systolic pressure or pulmonary hypertension and comorbid diabetes mellitus. 14 , 21 , 22) …”

“… 2 , 21) Independent factors associated with persistent MR post AVR were analyzed in 3 studies and 2 of these identified significant comorbid factors, which included elevated right ventricular systolic pressure or pulmonary hypertension and comorbid diabetes mellitus. 14 , 21 , 22) …”

“…24) The afterload reduction and easing of left ventricular systolic pressure following AVR may provide an initial reduction in MR severity, but the progressive ventricular reverse remodeling in the long term remains the true determinant of sustained improvements in MR. 10) There are several preoperative parameters that have been associated with improvements in MR including LV end-diastolic volume, left ventricular mass, left atrial diameter and ejection fraction; however, these have been inconsistently reported in the current literature. 2,10,20,21) The identification of more robust preoperative echocardiographic parameters requires consistent reporting of quantitative assessment methods used and this will ultimately help predict which patients exhibit an improvement in MR following an AVR. 23) The authors acknowledge the limitations of this review.…”