Impact of Preoperative Moderate/Severe Mitral Regurgitation on 2-Year Outcome After Transcatheter and Surgical Aortic Valve Replacement

Abstract

Background— The effect of preoperative mitral regurgitation (MR) on clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) is controversial. This study sought to examine the impact of moderate and severe MR on outcomes after TAVR and surgical aortic valve replacement (SAVR). Methods and Results— Data were drawn from the randomized Placement of Aortic Transcatheter Valve (PARTNER) Trial cohort A patients with severe, symptomatic aortic stenosis undergoing either TAVR (n=331) or SAVR (n=299). Both TAVR and SAVR patients were dichotomized according to the degree of preoperative MR (moderate/severe versus none/mild). At baseline, moderate or severe MR was reported in 65 TAVR patients (19.6%) and 63 SAVR patients (21.2%). At 30 days, among survivors who had isolated SAVR/TAVR, moderate/severe MR had improved in 25 SAVR patients (69.4%) and 30 TAVR patients (57.7%), was unchanged in 10 SAVR patients (27.8%) and 19 TAVR patients (36.5%), and worsened in 1 SAVR patient (2.8%) and 4 TAVR patients (5.8%; all P =NS). Mortality at 2 years was higher in SAVR patients with moderate or severe MR than in those with mild or less MR (49.8% versus 28.1%; adjusted hazard ratio, 1.73; 95% confidence interval, 1.01–2.96; P =0.04). In contrast, MR severity at baseline did not affect mortality in TAVR patients (37.0% versus 32.7%, moderate/severe versus none/mild; hazard ratio, 1.14; 95% confidence interval, 0.72–1.78; P =0.58; P for interaction=0.05). Conclusions— Both TAVR and SAVR were associated with a significant early improvement in MR in survivors. However, moderate or severe MR at baseline was associated with increased 2-year mortality after SAVR but not after TAVR. TAVR may be a reasonable option in selected patients with combined aortic and mitral valve disease. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.

Risk Prediction in Aortic Valve Replacement: Incremental Value of the Preoperative Echocardiogram

“…An analysis from the PARTNER trial similarly showed that significant MR was associated with an HR of 1.77 for 2‐year mortality post‐SAVR 32. Despite the impact of MR on mortality, the optimal management of such patients with moderate MR undergoing SAVR is not clear, given that the operative risk of double‐valve surgery continues to be markedly greater than single‐valve surgery 33, 34…”

Concomitant significant mitral regurgitation in patients with aortic valve stenosis undergoing valve replacement: Practical indications

“…Takeda et al 9 showed a significantly higher rate of re-hospitalization for heart failure in patients with concomitant significant MR compared with non/trivial and, among patients with significant Mr, a trend for a higher re-admission rate for patients without any improvement in Mr after aVr. on the other hand, the partNer study 7 showed an improvement in Nyha functional class after both surgical aVr and taVr which was independent on the presence and severity of concomitant Mr. a similar result emerged from a study by toggweiler et al 12 on patients undergoing taVr, with a general improvement in Nyha class regardless of Mr grade.…”

“…a 2011 meta-analysis performed on 17 studies concluded that patients with moderate/severe Mr had higher mortality compared to mild or no Mr at 30 days (or 0.41; CI at 95%: 0.24-0.72), and worse survival at 3 years (hr 0.49; CI at 95%: 0.35-0.69), 5 years (hr 0.46; CI at 95%: 0.34-0.61) and 10 years (hr 0.61; CI at 95%: 0.40-0.92)after aVr 10 . More recently, the partNer study 7 showed an increased mortality during a 24 months follow-up in patients with significant MR among 299 patients undergoing surgical aVr (hr 1.96; CI at 95%: 1.26-3.06).…”

“…the role of functional etiology as a predictor of Mr improvement after taVr is highlighted by toggweiler et al 12 in a study on 478 patients. depressed lV ejection fraction and larger lV diameters have also been associated with better improvement of Mr 7,25,26,27 , while calcific degeneration of mitral valve 25 , atrial fibrillation, large left atrial size and pulmonary arterial hypertension have been found to be associated with lack of improvement in Mr after aVr 6,28,29,30 . Furthermore, a 2010 study by Matsumura et al 31 identified preoperative tenting area, tenting height and mitral annulus area -measured by standard echocardiography -as independent predictors of persistent Mr after aVr.…”

Transcatheter aortic valve replacement: Are we ready to expand the use?

“…Moreover, patients with SAS and mitral regurgitation included in the PART-NER trial had a higher mortality rate at follow-up with isolated SAVR in comparison with TAVR without mitral valve repair or replacement [28].…”