Significant Mitral Regurgitation Left Untreated at the Time of Aortic Valve Replacement

Abstract

Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients.

Pathophysiology and management of multivalvular disease

“…In turn, LV dilation and adverse remodelling can be accompanied by secondary mitral regurgitation owing to mitral annular dilation and leaflet tethering (FIGURE 1) 18 . Elderly patients (>70 years old) with aortic stenosis often also have coronary artery disease, thus explaining the high prevalence of concomitant secondary ischaemic mitral regurgitation in this population 12, 19 . Alternatively, patients with aortic stenosis can have concomitant primary mitral regurgitation.…”

“…The severity of mitral regurgitation can be influenced by the presence of aortic valve disease 12, 18, 72 . After aortic valve replacement, the LV systolic pressure drops, thereby reducing the transmitral pressure gradient.…”

“…These common forms of mitral and tricuspid regurgitation, classified as secondary regurgitation, result from alterations of the geometry of the left or right ventricle, respectively 11 . In a recent review, secondary mitral regurgitation accounted for approximately 50% of patients with mitral regurgitation undergoing transcatheter aortic valve implantation (TAVI) 12 . Coronary artery disease and a history of myocardial infarction are highly prevalent in patients with degenerative valve disease, and ischaemic mitral regurgitation is, therefore, common in the ageing population 13-16 , and thus in elderly patients with degenerative valve disease.…”

A Glimpse into the Future: In 2020, Which Patients will Undergo TAVI or SAVR?

“…However, in the TAVI era, these ideas have been challenged and now selective proximal vessel, clinically-driven revascularisation is preferred rather than complete revascularisation using percutaneous coronary intervention. 50,51 A number of factors must be considered in managing patients with severe AS and concomitant CAD, including the timing of percutaneous coronary intervention (before, during, or after TAVI) and the complexity of coronary lesions. 50,51 Dedicated clinical trials are ongoing and should provide more definitive evidence-based guidelines.…”

“…50,51 A number of factors must be considered in managing patients with severe AS and concomitant CAD, including the timing of percutaneous coronary intervention (before, during, or after TAVI) and the complexity of coronary lesions. 50,51 Dedicated clinical trials are ongoing and should provide more definitive evidence-based guidelines. haemodynamically relevant MR after TAVI and continued symptoms of heart failure, a new approach is staged or simultaneous treatment with percutaneous mitral valve repair using the MitraClip system (Abbott Laboratories).…”