Transcatheter Aortic Valve Replacement and Concomitant Mitral Regurgitation

Abstract

Mitral regurgitation frequently coexists in patients with severe aortic stenosis. Patients with moderate to severe mitral regurgitation at the time of transcatheter aortic valve replacement are at increased risk of future adverse events. Whether concomitant mitral regurgitation is independently associated with worse outcomes after TAVR remains a matter of debate. The optimal therapeutic strategy in these patients—TAVR with evidence-based heart failure therapy, combined TAVR and transcatheter mitral valve intervention, or staged transcatheter therapies—is ill-defined, and guideline-based recommendations in patients at increased risk for open heart surgery are lacking. Hence, a thorough evaluation of the aortic and mitral valve anatomy and function, along with an in-depth assessment of the patients' baseline risk profile, provides the basis for an individualized treatment approach. The aim of this review is therefore to give an overview of the current literature on mitral regurgitation in TAVR, focusing on different diagnostic and therapeutic strategies and optimal clinical decision making.

Mitral annular disjunction in patients with severe aortic stenosis: Extent and reproducibility of measurements with computed tomography

“…Severe aortic stenosis and severe mitral regurgitation frequently coexists [ 18 , 19 ]. Whether mitral valve disease is independently associated with worse outcomes after TAVR remains a matter of debate [ 33 ]. Evidence-based recommendations and therapeutic strategies for concomitant severe aortic stenosis and mitral valve disease including surgical and transcatheter replacement and repair are still lacking due to insufficient data [ 28 ].…”

Transcatheter aortic valve implantation combined with other heart interventions: current status and future perspectives

“…Thus, a staged approach may be reasonable, with the aortic valve being addressed first, and the mitral valve treated only in those who remain symptomatic in spite of a successful TAVI. On the contrary, in the setting of a predominantly primary MR, as structural valve alterations are not expected to improve, bivalvular interventions should be advocated [25,28] .…”

One in one equals two

“…coexistent mitral regurgitation (MR) in patients undergoing native valve transcatheter aortic valve replacement (NV-TAVR) is both common and predictive of increased mortality, the prevalence and prognostic significance of concomitant MR in patients undergoing VIV-TAVR remain unknown [2][3][4]. The unexplored implications of MR in VIV-TAVR present a relevant clinical question as it serves as a steppingstone to understanding the optimal management strategy of these high-risk patients confronted with dual valve pathology.In this issue, Murdoch et al sought to provide insights into this question by conducting a prospective analysis of patients undergoing VIV-TAVR as derived from the PARTNER 2 Valve-in-Valve registry, an ongoing, multicenter, prospective study assessing patients with symptomatic degenerated aortic bioprosthetic surgical valves.…”

“…With the advent of transcatheter implantation of aortic bioprostheses in native stenotic valve disease and associated outcome improvements, transcatheter aortic valve‐in‐valve (VIV) replacement has emerged as an enticing solution for the growing population of patients with bioprosthetic structural valve deterioration that are at high risk for conventional redo surgical aortic valve replacement 1 . While it has been demonstrated by observational studies that the presence of coexistent mitral regurgitation (MR) in patients undergoing native valve transcatheter aortic valve replacement (NV‐TAVR) is both common and predictive of increased mortality, the prevalence and prognostic significance of concomitant MR in patients undergoing VIV‐TAVR remain unknown 2‐4 . The unexplored implications of MR in VIV‐TAVR present a relevant clinical question as it serves as a steppingstone to understanding the optimal management strategy of these high‐risk patients confronted with dual valve pathology.…”

“…The present study suggests that perhaps a conservative approach to managing concomitant MR may be appropriate but is insufficient to provide any conclusive insights. Further exploration of these findings with the expanding data from this registry will be crucial to further refine these analyses, and to arrive to an informed treatment strategy for these high‐risk patients, including alluding the potential role of staged percutaneous mitral valve intervention which has been shown to be technically feasible after NV‐TAVR 3,4 …”