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Effect of TAVR on Concomitant Mitral Regurgitation
Quick Takes
- In patients with severe aortic stenosis and concomitant moderate or worse mitral regurgitation (MR), MR regressed in 44% after TAVR.
- Patients with persistent MR after TAVR had increased mortality compared to those with regression of MR or nonsignificant MR.
- Patients with persistent MR after TAVR with NYHA class III/IV symptoms had significantly increased mortality at 4 years.
Study Questions:
What is the impact of transcatheter aortic valve replacement (TAVR) on concomitant mitral regurgitation (MR) and mortality?
Methods:
This is a retrospective review of the International Aortic+Mitral TRAnsCatheter (AMTRAC) Valve Registry, a multicenter registry that has collected data on patients who have undergone TAVR and transcatheter mitral valve replacement/repair. This analysis includes patients treated with TAVR between January 2007 and December 2019 who also had assessment of MR pre-procedure and at 30 days post-TAVR. Patients with previous mitral valve surgery were excluded. Patients were divided into three groups: 1) nonsignificant MR (baseline MR was < moderate), 2) MR regression (baseline MR was ≥ moderate but regressed to < moderate after TAVR), and 3) MR persistence (both baseline and post-TAVR MR were ≥ moderate). Kaplan-Meier analysis and Cox proportional hazards modeling were performed for all-cause mortality. Logistic regression was used to determine predictors of MR regression or persistence. Propensity-score matching was used to compare a cohort of patients with MR persistence who did or did not undergo percutaneous mitral valve repair (PMVR).
Results:
Out of 12,472 patients in the registry, baseline and 30-day post-TAVR MR grade was available in 7,303 (58.6%). Of those, 1,983 (27.2%) had ≥ moderate MR (or significant MR). There were 874 patients in the MR regression group and 1,109 in the MR persistence group. Median follow-up was 3.3 years (interquartile range, 2.5-4.3 years). At 4 years, the KM estimate for cumulative all-cause mortality was 32.4% in the nonsignificant MR group, 35.1% in the MR regression group, and 43.8% in the MR persistence group. The difference in mortality between the MR persistence group and both other groups was significant (p < 0.01). Multivariate-adjusted hazard ratio (HR) for mortality between the MR persistence and nonsignificant MR groups was 1.38 (95% confidence interval [CI], 1.06-2.04; p = 0.008).
More patients in the MR persistence group had New York Heart Association (NYHA) class III/IV symptoms compared to the nonsignificant MR and MR regression groups (14.4% vs. 4.0% vs. 3.8%, p < 0.001), and at 4 years, those with NYHA class III/IV symptoms had significantly increased mortality of 54.7% (95% CI, 38.1-71.3%, log rank p < 0.001). In univariate logistic regression, patients with baseline severe MR, atrial fibrillation, moderate or worse mitral annulus or mitral leaflet calcification, systolic pulmonary artery pressure >45 mm Hg, degenerative MR, and self-expanding TAVR valve were less likely to have regression of MR. Patients in the MR persistence group who were >80 years old, male, had atrial fibrillation, and had degenerative MR were at greater odds of remaining in NYHA class III/IV.
Among 91 propensity-matched pairs of patients with MR persistence who did or did not undergo staged PMVR, at 6- and 12-month follow-up, NYHA class improved significantly in the group that underwent staged PMVR (6-month: 19.1% vs. 68.0%; 12-month: 17.6% vs. 66.7%). Mortality at 4 years was not significantly different overall (univariate HR, 1.66; 95% CI, 0.94-2.86; p = 0.097).
Conclusions:
Significant MR improves in 44% of patients after TAVR, but those with persistent MR post-TAVR have increased mortality, especially those with NYHA class III/IV symptoms. Staged PMVR improves NYHA class, but not necessarily mortality.
Perspective:
This study provides guidance for the 56% of patients for whom TAVR may not improve moderate or worse MR. Patients post-TAVR should be followed closely and a plan for mitral intervention established depending on MR grade on surveillance echocardiograms and severity of symptoms attributable to MR, as PMVR may offer a mechanism by which these patients can achieve symptom benefit. Survival benefit with staged PMVR will require further studies with larger sample size, more data granularity, and longer-term follow-up. Of note, this study could only include 59% of the total AMTRAC registry patients due to missing data on post-TAVR MR. This may be an important data field to assess for completeness in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry to examine outcomes of TAVR with staged PMVR in the United States.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Aged, 80 and over, Aortic Valve Stenosis, Atrial Fibrillation, Cardiac Surgical Procedures, Echocardiography, Geriatrics, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement
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