Clinical Impact of Aortic Regurgitation After Transcatheter Aortic Valve Replacement: Insights Into the Degree and Acuteness of Presentation
Is there a difference in mortality in patients with acute versus chronic moderate to severe aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR)?
This study examined 1,735 consecutive patients undergoing TAVR at eight centers (balloon-expandable n = 982, self-expanding n = 753), and evaluated predictors of mortality. AR was graded using transthoracic echocardiography after the procedure using Valve Academic Research Consortium 2 (VARC-2) criteria, and acute moderate/severe AR was defined as an increase of ≥1 grade in comparison to baseline.
Following TAVR, mild AR was observed in 43.9% of patients and moderate/severe AR was seen in 14.2%. Mean follow-up was 21 ± 17 months. At 30 days, unadjusted rates of mortality were 4.3%, 4.6%, and 11.7% in patients with absent/trace, mild, and moderate/severe AR, respectively (p < 0.001). In comparison to patients with absent/trace AR, multivariable analysis observed no significant difference in long-term mortality in those with mild AR (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.84-1.37; p = 0.57), although increased mortality was observed in patients with moderate/severe AR (HR, 1.81; 95% CI, 1.32-2.48; p < 0.001). Compared to individuals with absent/trace/mild AR, multivariable analysis observed no difference in long-term mortality in patients with chronic moderate/severe AR (HR, 1.06; 95% CI, 0.60-1.86; p = 0.85), while those with acute moderate/severe AR had increased mortality (HR, 2.37; 95% CI, 1.53-3.66; p < 0.001).
The authors concluded that acute moderate to severe AR following TAVR is associated with increased mortality, while mild or chronic moderate to severe AR are not.
The majority of patients undergoing TAVR have residual AR following device deployment. Additional procedures such as balloon post-dilation or deployment of a second valve can be used to reduce AR following initial device deployment, but these introduce additional risks such as stroke or annular rupture that must be weighed against the risk of continued AR. Previous studies have demonstrated that moderate/severe AR is associated with increased mortality, while reports on the risk of mild AR have been variable. This study finds that only acute moderate/severe AR predicts mortality, while chronic moderate/severe AR and mild AR do not. These results suggest that additional procedures to treat AR following initial device deployment should be focused on those with acute moderate to severe AR.
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