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TAVR for Mixed Aortic Stenosis and Regurgitation
Study Questions:
How do the outcomes after transcatheter aortic valve replacement (TAVR) among patients with mixed aortic valve disease (MAVD; defined as aortic stenosis [AS] and at least mild aortic regurgitation [AR]) compare to those among patients with pure AS (no or trivial AR)?
Methods:
In a single-center, retrospective, observational study, data from 1,133 patients who underwent transfemoral-access TAVR for native valve AS between January 2014 and December 2017 were included. The primary outcome was all-cause mortality; secondary outcomes included composite endpoints of early safety and clinical efficacy by Valve Academic Research Consortium-2 criteria. Comparisons were adjusted to account for post-TAVR AR development in both groups.
Results:
A total of 688 patients (61%) had MAVD (median age 83 years, 43% female). Among these, 17% had mild, 2% moderate, and <1% severe post-TAVR AR. Overall, patients with MAVD had better survival when compared to patients with pure AS (p = 0.03). Among patients who developed post-TAVR AR, those in the MAVD group had better survival (p = 0.04); in contrast, among patients who did not develop post-TAVR, pre-TAVR AR was not associated with improved survival (p = 0.11).
Conclusions:
Patients with MAVD who underwent TAVR had better survival compared to patients with pure AS, driven by better survival with pre-existing AR among patients who had AR following TAVR. The authors concluded that this is potentially mediated by pre-existing left ventricular adaptation to AR.
Perspective:
There are conflicting data about whether and to what degree AR following TAVR affects survival. Although it is not stated, it is likely that this study included predominantly if not exclusively patients who underwent implantation of a balloon-expandable TAVR, for which post-procedure AR has been associated with a worse prognosis. If in this population post-TAVR AR exposes a thick, noncompliant left ventricle to an acute volume overload, then it makes some intuitive sense that pre-TAVR AR might be protective in the setting of post-TAVR AR. However, the study findings should be validated in a larger multicenter (and potentially multi-device) study. In as much as currently approved devices for TAVR are indicated for the treatment of calcific AS, patients in this study presumably underwent TAVR for dominant AS; this study does not address a population who underwent TAVR for dominant AR.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Aortic Valve Insufficiency, Aortic Valve Stenosis, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Prognosis, Transcatheter Aortic Valve Replacement, Treatment Outcome
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