Transcatheter aortic valve replacement outcomes in mixed aortic valve disease compared to predominant aortic stenosis

Heidari, Behnam; Al-Hijji, ‪Mohammed; Alkhouli, Mohamad; Egbe, Alexander C.; Welle, Garrett A.; Eleid, Mackram F.; Singh, Mandeep; Gulati, Rajiv; Rihal, Charanjit S.; Lerman, Amir

doi:10.1016/j.ijcard.2019.07.099

Cited by 18 publications

(23 citation statements)

References 33 publications

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“…The discordance observed between echocardiographic grading and clinical outcomes may be due to the limitations of valvular flow parameters. With patients with mixed AS/AR requiring more urgent transcatheter aortic valve implantation (TAVI) compared with isolated severe AS, current echocardiographic grading of mixed AS/AR could be under-recognising clinical severity 34. An integrative assessment of clinical factors, valve and cardiac size and function in mixed AS/AR could be more informative in grading lesion severity.…”

Section: Diagnosis and Quantificationmentioning

confidence: 99%

“…Patients greater than 65 years of age most likely have calcific mixed AS/AR and are recommended for TAVI or tissue AVR. Up to 20% of patients referred for TAVI have mixed AS/AR,34 and while the majority of studies have shown non-inferior or superior survival of patients with mixed AS/AR versus patients with isolated AS, one study reported increased mortality in patients with mixed AS/AR (table 3). 34 41–46 Of importance, the mixed survival benefit of TAVI in mixed AS/AR occurs despite consistent findings of higher rates of paravalvular regurgitation (15.5% vs 6.7%, p=0.004) and lower rates of device success (81.0% vs 88.9%, p=0.027) in patients with mixed AS/AR 34 47.…”

Section: Managementmentioning

confidence: 99%

“…Up to 20% of patients referred for TAVI have mixed AS/AR,34 and while the majority of studies have shown non-inferior or superior survival of patients with mixed AS/AR versus patients with isolated AS, one study reported increased mortality in patients with mixed AS/AR (table 3). 34 41–46 Of importance, the mixed survival benefit of TAVI in mixed AS/AR occurs despite consistent findings of higher rates of paravalvular regurgitation (15.5% vs 6.7%, p=0.004) and lower rates of device success (81.0% vs 88.9%, p=0.027) in patients with mixed AS/AR 34 47. The mechanism by which mixed AS/AR confers a potential benefit in TAVI is postulated to be due to increased tolerance of paravalvular regurgitation, as among patients with paravalvular regurgitation those who had mixed AS/AR had better survival 44.…”

Section: Managementmentioning

confidence: 99%

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Mixed aortic stenosis and regurgitation: a clinical conundrum

Nedadur

Belzile

Farrell

et al. 2022

Heart

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Mixed aortic stenosis (AS) and aortic regurgitation (AR) is the most frequent concomitant valve disease worldwide and represents a heterogeneous population ranging from mild AS with severe AR to mild AR with severe AS. About 6.8% of patients with at least moderate AS will also have moderate or greater AR, and 17.9% of patients with at least moderate AR will suffer from moderate or greater AS. Interest in mixed AS/AR has increased, with studies demonstrating that patients with moderate mixed AS/AR have similar outcomes to those with isolated severe AS. The diagnosis and quantification of mixed AS/AR severity are predominantly echocardiography-based, but the combined lesions lead to significant limitations in the assessment. Aortic valve peak velocity is the best parameter to evaluate the combined haemodynamic impact of both lesions, with a peak velocity greater than 4.0 m/s suggesting severe mixed AS/AR. Moreover, symptoms, increased left ventricular wall thickness and filling pressures, and abnormal left ventricular global longitudinal strain likely identify high-risk patients who may benefit from closer follow-up. Although guidelines recommend interventions based on the predominant lesion, some patients could potentially benefit from earlier intervention. Once a patient is deemed to require intervention, for patients receiving transcatheter valves, the presence of mixed AS/AR could confer benefit to those at high risk of paravalvular leak. Overall, the current approach of managing patients based on the dominant lesion might be too reductionist and a more holistic approach including biomarkers and multimodality imaging cardiac remodelling and inflammation data might be more appropriate.

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Section: Diagnosis and Quantificationmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

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Mixed aortic stenosis and regurgitation: a clinical conundrum

Nedadur

Belzile

Farrell

et al. 2022

Heart

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“…2 In clinical practice, the proportion of patients with mixed aortic valve disease treated by TAVR, commonly seen as severe AS with any degree of concomitant AR, can be quite high. 3,4 As pre-existing AR results in volume overload with subsequent left ventricular (LV) dilatation and eccentric hypertrophy, 5 the anatomy of aortic root and LV will be different among patients with isolated AS and AS plus different degree of AR. Concomitant mild or more severe AR has been shown to have survival protection to TAVR patients especially in those who developed post-TAVR AR, 4 likely due to left ventricular adaptation to AR.…”

Section: Introductionmentioning

confidence: 99%

“…It has also been utilized in patients with isolated aortic regurgitation (AR) 2 . In clinical practice, the proportion of patients with mixed aortic valve disease treated by TAVR, commonly seen as severe AS with any degree of concomitant AR, can be quite high 3,4 . As pre‐existing AR results in volume overload with subsequent left ventricular (LV) dilatation and eccentric hypertrophy, 5 the anatomy of aortic root and LV will be different among patients with isolated AS and AS plus different degree of AR.…”

Section: Introductionmentioning

confidence: 99%

Effect of concomitant aortic regurgitation on early hypo‐attenuated leaflet thickening after transcatheter aortic valve replacement in patients with symptomatic severe aortic stenosis

Xiong

Liao

et al. 2020

Cathet Cardio Intervent

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Objective: We hypothesize that different degree of pre-existing aortic regurgitation (AR) may affect the presence of hypo-attenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR). Background: The mechanism of the presence of HALT post-TAVR is not fully understood. Methods: We retrospectively evaluated the post-procedural multi-slice computed tomography (MSCT) before discharge for evidence of HALT. Patients were grouped according to the degree of pre-existing AR. Baseline, native anatomy and procedure details were compared, then multivariate regression was performed. Results: MSCT analyzed was performed at a median of 6 days post-TAVR in 179 patients. HALT was detected in 10.6% of patients. After adjusting for variables that were significantly different between groups, pre-existing ≥ moderate AR was protective to the risk of HALT (OR 0.15, 95% CI 0.03-0.84, p = .03). Stratifying for factors that might explain the impact of pre-existing AR on HALT, patients with a small Sinus of Valsalva, non-eccentric remodeling and receiving a large bioprosthesis experienced a sevenfold higher risk for HALT (OR 7.16, 95% CI 2.05-25.08, p = .002).

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