Vol 31, No 6 (2024)
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The impact of transcatheter aortic valve implantation (TAVI) on mitral regurgitation — a single center study

Elżbieta Ostrowska-Kaim12, Jarosław Trębacz1, Paweł Kleczyński13, Robert Sobczynski4, Janusz Konstanty-Kalandyk45, Robert Musiał6, Andrzej Gackowski27, Jacek Legutko13, Krzysztof Żmudka13, Bogusław Kapelak45, Maciej Stąpór12
Pubmed: 39110126
Cardiol J 2024;31(6):833-842.

Abstract

Background: The coexistence of mitral regurgitation (MR) and severe aortic stenosis (AS) has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Herein, the aim was to assess the etiology and degree of MR in an unselected TAVI population and investigate the impact of MR reduction at mid-term follow-up.

Methods: Patients subjected to TAVI as a treatment for severe AS in a single center were retrospectively analyzed. The primary endpoint was the MR reduction after TAVI. The secondary endpoint was all-cause mortality and heart failure hospitalization at a 3-year follow-up.

Results: Patients undergoing TAVI (n = 283) in the years 2017–2019 were screened for the presence of hemodynamically significant MR. Sixty-nine subjects (24.4%) with severe (16, 23.2%) and moderate (53, 76.8%) MR were included. The primary MR was predominant (39 subjects, 56.5%). The median age of the patients was 82 years. MR improved in 25 patients (36.2%, p < 0.001). Baseline severe MR was more prone to reduce (8 subjects, 50%) than moderate (17 subjects, 32.1%, p = 0.04). The primary MR improved in 14 patients (35.9%), while secondary in 11 patients (36.7%, p = 1). Patients showing MR reduction had lower mortality (8 vs. 29.55%, p = 0.047) and were less frequently hospitalized (20 vs. 45.45%, p = 0.03) at 3-year follow-up.

Conclusions: Hemodynamically significant MR improves after TAVI regardless of its etiology. Moreover, MR reduction after TAVI is associated with better clinical outcomes.

clinicAL CARDIOLOGY

Original article

Cardiology Journal

2024, Vol. 31, No. 6, 833–842

DOI: 10.5603/cj.98792

Copyright © 2024 Via Medica

ISSN 1897–5593

eISSN 1898–018X

The impact of transcatheter aortic valve implantation (TAVI) on mitral regurgitation — a single center study

Elżbieta Ostrowska-Kaim12Jarosław Trębacz1Paweł Kleczyński13Robert Sobczynski4Janusz Konstanty-Kalandyk45Robert Musiał6Andrzej Gackowski27Jacek Legutko13Krzysztof Żmudka13Bogusław Kapelak45Maciej Stąpór12
1Clinical Department of Interventional Cardiology, St. John Paul II Hospital, Krakow, Poland
2Noninvasive Cardiovascular Laboratory, St. John Paul II Hospital, Krakow, Poland
3Department of Interventional Cardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, St. John Paul II Hospital, Krakow, Poland
4Department of Cardiovascular Surgery and Transplantology, St. John Paul II Hospital, Krakow, Poland
5Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, St. John Paul II Hospital, Krakow, Poland
6Third Department of Anesthesiology and Intensive Therapy, St. John Paul II Hospital, Krakow, Poland
7Department of Coronary Disease and Heart Failure, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, St. John Paul II Hospital, Krakow, Poland

Address for correspondence: Maciej Stąpór, MD, PhD, Interventional Cardiology, John Paul II Hospital, ul. Prądnicka 80, 31–202 Kraków, Poland, e-mail: m.stapor@szpitaljp2.krakow.pl, tel: +48126143501, fax: +48126143047

Date submitted: 04.01.2024 Date accepted: 15.07.2024 Early publication date: 7.08.2024

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

Abstract
Background: The coexistence of mitral regurgitation (MR) and severe aortic stenosis (AS) has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Herein, the aim was to assess the etiology and degree of MR in an unselected TAVI population and investigate the impact of MR reduction at mid-term follow-up.
Methods: Patients subjected to TAVI as a treatment for severe AS in a single center were retrospectively analyzed. The primary endpoint was the MR reduction after TAVI. The secondary endpoint was all-cause mortality and heart failure hospitalization at a 3-year follow-up.
Results: Patients undergoing TAVI (n = 283) in the years 2017–2019 were screened for the presence of hemodynamically significant MR. Sixty-nine subjects (24.4%) with severe (16, 23.2%) and moderate (53, 76.8%) MR were included. The primary MR was predominant (39 subjects, 56.5%). The median age of the patients was 82 years. MR improved in 25 patients (36.2%, p < 0.001). Baseline severe MR was more prone to reduce (8 subjects, 50%) than moderate (17 subjects, 32.1%, p = 0.04). The primary MR improved in 14 patients (35.9%), while secondary in 11 patients (36.7%, p = 1). Patients showing MR reduction had lower mortality (8 vs. 29.55%, p = 0.047) and were less frequently hospitalized (20 vs. 45.45%, p = 0.03) at 3-year follow-up.
Conclusions: Hemodynamically significant MR improves after TAVI regardless of its etiology. Moreover, MR reduction after TAVI is associated with better clinical outcomes. (Cardiol J 2024; 31, 6: 833–842)
Keywords: aortic stenosis, mitral regurgitation, TAVI, transcatheter aortic valve implantation, TAVR, transcatheter aortic valve replacement

Introduction

Mitral regurgitation (MR) and severe aortic stenosis (AS) coexist in one-third of the patients, reaching up to 48% in the elderly [1, 2]. Patients with severe MR have often been excluded from randomized TAVI (transcatheter aortic valve implantation) trials [3]. In this setting, the MR is usually secondary to the AS (functional MR), while the primary MR (organic) is less common [2, 4]. The co-occurrence of severe AS and significant MR has been associated with worse outcomes [5–9].

TAVI is offered as a treatment in patients with severe AS at intermediate and high surgical risk [10–12].

A significant improvement in MR severity is well documented and was detected in more than 50% of the patients following TAVI [7, 8]. Nevertheless, the aim was to assess changes in MR in an Eastern European population of unselected TAVI patients with a relatively high prevalence of rheumatic valve disease.

Methods

Study design and population

This was a retrospective analysis of consecutive patients subjected to TAVI as a treatment for severe AS between January 2017 and December 2019 in a single center. Patients with at least moderate MR were included. Nonsignificant MR and previous mitral valve (MV) intervention were excluded from the study.

The primary endpoint was MR reduction following TAVI, and the secondary endpoint was all-cause mortality and heart failure hospitalization at a 3-year follow-up. The outcome reporting complied with standardized VARC-2 (Valve Academic Consortium) consensus definitions [13].

Echocardiography

MR was assessed at baseline, discharge, and at 3 and 6–12 months after the procedure. Philips iE33 and Cx50 systems (Philips Ultrasound, Bothell, Washington, United States) were used for transthoracic echocardiography (TTE). Loops and images were stored in the DICOM format.

TTEs were acquired by cardiologists, certified by the European Association of Cardiovascular Imaging (EACVI). The deferred image analyses were performed by two experienced cardiologists, blinded to clinical data, using ComPACS (Medimatic S.R.L., Genova, Italy) and QLAB (Philips Medical Systems, Andover, Massachusetts, United States) workstations.

Baseline moderate and severe MR were considered clinically significant. MR was classified as primary (i.e. organic/structural) or secondary (i.e. functional/non-structural) according to EACVI (European Association of Cardiovascular Imaging) recommendations [14]. Postprocedural MR reduction of at least one grade was recognized as an improvement. When quantitative evaluation of MR was not feasible, qualitative parameters were taken into account.

Ethical issues

Due to the retrospective character, the ethical review and approval were waived for this study. However, the institutional board was informed and acknowledged the analysis. The investigation conforms with the principles outlined in the 1964 Declaration of Helsinki and its later amendments.

Statistical analysis

The tests for the assessment of normality were: Lilliefors, Shapiro-Wilk, Jarque–Bera and Kolmogorov–Smirnov. When any of these rejected the hypothesis of a normal distribution, non-parametric calculations were used. Continuous variables with normal distribution were presented as mean and standard deviation (SD). Non-normally distributed variables were reported as median and interquartile range (IQR). Categorical variables were presented as numbers and percentages (%). Unpaired samples t-test for normally distributed variables and Wilcoxon rank-sum test for non-parametric variables were used. Fisher’s exact test and Pearson’s chi-squared tests for unpaired categorical data were applied. Event-free survival was estimated using the Kaplan-Meier method. The log-rank test was used to compare subgroups stratified according to MR reduction. Statistical analyses were performed by use of Statistica 13.3 (Tibco Software Inc., Palo Alto, California, United States). A two-tailed p-value less than 0.05 was considered significant.

Results

Clinical data

Patients undergoing TAVI in years 2017–2019 (n = 283) were screened for the presence of hemodynamically significant MR. Two hundred fourteen subjects were excluded due to insignificant MR or previous MV surgery. Finally, 69 patients (24.4%) were included, 16 with severe and 53 with moderate MR. Etiology of MR was classified either as primary (39, 56.5%) or secondary (30, 43.5%). All subjects underwent follow-up visits. The study flowchart is presented in Figure 1.

Figure 1. Study flowchart; MR — mitral regurgitation; MV — mitral valve; TAVI — transcatheter aortic valve implantation

The median age of the patients was 82 years, overweight women predominated in the study group (45, 65.2%). Subjects had advanced heart failure symptoms and an intermediate operative risk profile. The majority of patients had high-gradient AS (43, 62.3%). However, 17 patients (24.6%) had low-flow, low-gradient AS with reduced ejection fraction (EF) and 9 (13%) low-flow, low-gradient AS with preserved EF.

Self-expandable valves were mostly used (54, 78.3%). CoreValve/Evolut R/Evolut Pro valves (Medtronic, Dublin, Ireland) were commonly implanted (29, 42%), followed by SymetisAcurate/Acurateneo2(Boston Scientific, Ecublens, Switzerland; 21, 30.4%) and Portico (St. Jude Medical, Minneapolis, MN, USA; 2, 2.9%). Balloon-expandable Sapien XT/Sapien 3 (Edwards Lifescience, Irvine, CA, USA) valves were used in 15 (21.7%) subjects. There were no perioperative deaths. Six patients (8.7%) required pacemaker implantation, two subjects (2.9%) suffered a non-disabling stroke and one (1.5%) a non-fatal tamponade.

The clinical, biochemical, echocardiographic and procedural data are summarized in Tables 1–3.

Table 1. Clinical characteristics

Total
n = 69

Moderate MR
n = 53 (76.8%)

Severe MR
n = 16 (23.2%)

P

No MR reductionn = 44 (63.8%)

MR reductionn = 25 (36.2%)

P

Age, median (IQR), years

82 (80–85)

82 (80–85)

82 (79.75–
–84.25)

0.743

82 (79.5–84.5)

83.5 (80.25–85)

0.188

Female, n [%]

45 (65.2)

33 (62.3)

12 (75)

0.389

27 (61.4)

18 (72)

0.437

BMI, mean (SD), kg/m2

27.5 (47)

27.7 (4.9)

27 (4.6)

0.648

28.2 (5.2)

26.2 (3.6)

0.141

NYHA class III–
–IV, n [%]

53 (76.8)

40 (75.5)

13 (81.3)

0.598

36 (81.8)

17 (68)

0.456

Diabetes, n [%]

21 (30.4)

17 (32.1)

4 (25)

0.444

12 (27.3)

9 (36)

0.972

Hypertension, n [%]

60 (87)

45 (84.9)

15 (93.8)

0.107

38 (86.4)

22 (88)

0.096

Nicotynism, n [%]

8 (11.6)

8 (15.1)

0

0.695

7 (15.9)

1 (4)

0.73

Prior PCI, n [%]

23 (33.3)

17 (32.1)

6 (37.5)

0.607

14 (31.8)

9 (36)

0.038

Priormyocardialinfarction, n [%]

19 (27.5)

14 (26.4)

5 (31.3)

0.081

16 (36.4)

3 (12)

0.357

Prior CABG, n [%]

9 (13)

9 (17)

0

0.717

7 (15.9)

2 (8)

0.312

Atrialfibrilation, n [%]

36 (52.2)

27 (50.9)

9 (56.3)

0.640

25 (56.8)

11 (44)

0.197

COPD, n [%]

7 (10.1)

6 (11.3)

1 (6.3)

0.613

7 (15.9)

0

0.035

Hemoglobin, mean (SD), g/dL

11.7 (1.8)

11.8 (1.9)

11.2 (1.2)

0.262

11.7 (1.6)

10.3 (1.5)

0.856

Chronic kidney disease (eGFR < 60mL/min/m2), n [%]

47 (68.1)

36 (67.9)

11 (68.8)

0.957

35 (79.5)

12 (48)

0.007

eGFR, median (IQR), mL/min/m2

51 (40–64)

53 (42–64)

49.50 (40–
–60.75)

0.664

50.5 (40–58)

60 (42–67)

0.25

Creatinine, median (IQR), umol/L

96 (84–113)

97 (84–113)

93 (87–112)

0.971

98.5 (85–118.25)

93 (81–108)

0.274

NT-proBNP, median (IQR), pg/mL

3740 (1985–10403)

3583 (2069–10279)

4127 (1404–11114)

0.973

3467 (1976–
–10155)

4766 (2028–
–10155)

0.512

NT–proBNP
> 3000 pg/mL, n [%]

35 (50.7)

26 (49.1)

9 (56.3)

0.759

22 (50)

13 (52)

0.764

Pacemaker, n [%]

19 (27.5)

13 (24.5)

6 (37.5)

0.316

12 (27.3)

7 (28)

0.954

Bundle branchblock, n [%]

13 (18.8)

11 (20.8)

2 (12.5)

0.468

9 (20.5)

4 (16)

0.658

STS-PROM, median (IQR), %

4.77 (3.4–
–6.1)

4.43 (3.2–
–4.95)

4.57 (3.5–
–5.9)

0.738

4.99 (3.92–5.7)

4.23 (3.54–
–4.95)

0.774

EuroScore II, median (IQR), %

5.32 (4.29–7.9)

4.94 (4.03–7.5)

5.51 (4.39–7.9)

0.569

4.9 (3.65–7.6)

5.46 (4.17–
–7.61)

0.644

Table 2. Baseline echocardiographic variables

Total

n = 69

Moderate MR
n = 53 (76.8%)

Severe MR
n = 16 (23.2%)

P

No MR reduction n = 44 (63.8%)

MR reduction n = 25 (36.2%)

P

Chambers

LVEDD, median (IQR), mm

50 (45–55)

50 (45–54)

48 (39.25–
–57.75)

0.507

49 (45–53)

51.5 (41–55.5)

0.637

LVEF, median (IQR), %

55 (40–60)

52.5 (40–60)

59 (44.7–65)

0.210

53 (39–65)

55 (40–60)

0.537

Left atrium area, mean (SD), cm2

30.4 (6.4)

27.3 (6.2)

31.2 (6.32)

0.044

30.5 (6.7)

30.1 (5.9)

0.789

Aortic valve

Peak aortic gradient, mean (SD), mmHg

71.2 (29.2)

71.4 (30.8)

72 (28.9)

0.878

75.6 (32.1)

64.6 (25.5)

0.274

Mean aortic gradient, mean (SD), mmHg

43.7 (17.3)

43.9 (17.2)

43.2 (18.3)

0.906

45.2 (19)

41.0 (13.8)

0.363

Aortic valve area, median (IQR), cm2

0.64 (0.5–
–0.9)

0.7 (0.5–
–0.9)

0.57 (0.5–0.77)

0.443

0.67 (0.5–
–0.8)

0.6 (0.6–0.9)

0.329

Aortic valve area index, median (IQR), cm2/m2

0.42 (0.32–
–0.49)

0.43 (0.36–0.53)

0.37 (0.29–
–0.45)

0.143

0.39 (0.35–
–0.48)

0.45 (0.32–0.54)

0.488

Moderate to severe AR, n [%]

38 (55.1)

28 (52.8)

10 (62.5)

0.117

25 (56.8)

13 (52)

0.938

Mitral valve

Mitral annulus, mean (SD), mm

34.8 (6.3)

31.4 (8.4)

35.6 (5.4)

0.024

35.6 (5.6)

33.3 (7.39)

0.170

Mean mitral gradient, median (IQR), mmHg

2 (1.5–3)

2 (1.5–3)

3 (2.15–4.25)

0.529

2 (1.45–3)

2 (1.55–4)

0.643

MR etiology

Primary, n [%]

39 (56.5)

30 (56.6)

9 (56.3)

1

25 (56.8)

14 (56)

1

Secondary, n [%]

30 (43.5)

23 (43.4)

7 (43.8)

19 (43.2)

11 (44)

MR vena contracta, median (IQR), cm

0.53 (0.32–
–0.79)

0.4 (0.25–
–0.54)

1.03 (0.85–
–1.08)

< 0.001

0.53 (0.31–
–0.73)

0.53 (0.33–0.92)

0.727

MR EROA, median (IQR), cm2

0.3(0.15–
–0.57)

0.2(0.1–
–0.31)

0.71 (0.57–
–0.82)

< 0.001

0.28 (0.1–
–0.46)

0.33 (0.17–0.57)

0.267

MR regurgitant volume, median (IQR), mL

49 (40–66)

43.5 (36–51)

78 (69–84)

< 0.001

48 (41–64)

51 (40–66)

0.617

Tricuspid valve

Moderate to severe TR, n [%]

33 (47.8)

25 (47.2)

8 (50)

0.609

24 (54)

9 (36)

0.172

Pulmonary systolic artery pressure, mean (SD), mmHg

45.7 (17.9)

45.5 (29.8)

46.5 (20.9)

0.898

47 (27.7)

41.0 (13.8)

0.350

Table 3. Procedure, complications and outcomes

Total
n = 69

Moderate MR
n = 53 (76.8%)

Severe MR
n = 16 (23.2%)

P

No MR reduction n = 44 (63.8%)

MR reduction n = 25 (36.2%)

P

Procedure

Self-expandablevalves,
n [%]

54 (78.3)

39 (73.6)

15 (93.8)

0.094

34 (77.3)

18 (72)

0.772

Transfemoralaccess, n [%]

66 (95.7)

50 (94.3)

16 (100)

1

43 (97.7)

23 (92)

0.288

Complications

Highest creatinine, median (IQR), umol/L

109 (92–
–131)

109 (92–
–131)

107 (90.8–130.8)

0.915

113.5 (94.5–137.3)

104 (90–124)

0.127

Acute kidney injury, n [%]

12 (17.4)

10 (18.9)

2 (12.5)

0.566

9 (20.5)

3 (12)

0.381

Lowest hemoglobin, mean (SD), g/dL

10 (14.5)

10.1 (1.8)

11.2 (1.2)

0.479

9.9 (1.7)

10.3 (1.56)

0.329

Blood transfusion, n [%]

13 (18.8)

12 (22.6)

1 (6.3)

0.147

9 (20.5)

4 (16)

0.658

Pacemaker, n [%]

6 (8.7)

3 (5.7)

3 (18.8)

0.109

4 (9.1)

2 (8)

0.888

Stroke, n [%]

2 (2.9)

2 (3.8)

0

2 (4.5)

0

Tamponade, n [%]

1 (1.5)

1 (1.9)

0

1 (6.25)

0

Death, n [%]

0

0

0

N/A

0

0

N/A

Myocardial infarction, n [%]

0

0

0

N/A

0

0

N/A

Outcomes

All–causemortality, n [%]

15 (21.7)

11 (20.8)

4 (25)

0.732

13 (29.5)

2 (8)

0.047

Heart failure hospitalization, global, n [%]

25 (36.2)

18 (34)

7 (43.8)

0.478

20 (45.5)

5 (20)

0.03

All-cause mortality or heart failure hospitalization, n [%]

29 (42.1)

21 (39.6)

8 (50)

0.778

22 (50)

7 (28)

0.078

Primary endpoint

The quantitative evaluation of MR was feasible in 47 subjects (68.12%), with the others, a reliable qualitative appraisal was possible. MR improved in 25 patients (36.2%, p < 0.001, Figure 2).

Figure 2. Transthoracic echocardiography, color Doppler imaging; Baseline (A) and 5 months follow-up (B). Parasternal short-axis view (left), two-chamber view (center), four-chamber view (right). Reduction of mitral regurgitation (moderate to mild)

Baseline severe MR was more prone to reduce (8 subjects, 50%) than moderate (17 subjects, 32.1%, p = 0.04). The primary MR decreased in 14 patients (35.9%), while secondary in 11 patients (36.7%, p = 1). In 3 subjects MR increased from moderate to severe, unrelated to TAVI myocardial infarction (MI), pacemaker-induced asynchrony, and significant paravalvular leak, respectively.

Patients with MR reduction suffered less frequently from chronic obstructive pulmonary disease (0 vs. 15.9%, p=0.04) and chronic kidney disease (48 vs. 79.5%, p = 0.01). In this subgroup the preprocedural MI was less common (12 vs. 36.4%, p = 0.04). Moreover, there was a visible trend towards non-smoking (4% vs. 15.9%, p = 0.09) as well (Table 1).

In patients responding to TAVI with MR reduction, a lower postprocedural pulmonary systolic artery pressure (19.6 vs. 36.2mmHg, p = 0.02) and less common incidence of severe tricuspid regurgitation (12 vs. 36.4%, p = 0.01) were noticed, despite the lack of preprocedural differences (Tables 2 and 4). In addition, a trend of ejection fraction increase (3.9 vs 1.1%, p = 0.09) was detected in this subgroup.

Table 4. Follow-up echocardiographic variables

Total
n = 69

Moderate MR
n = 53 (76.8%)

Severe MR
n = 16 (23.2%)

P

No MR reduction n = 44 (63.8%)

MR reduction n = 25 (36.2%)

P

Chambers

LVEDD, median (IQR), mm

47.5. (44–
–52.8)

48 (44.5–53)

45 (42–48)

0.193

47.5 (44.75–52)

47.5 (43–53.8)

0.79

Postprocedural LVEDD reduction, mean (SD), mm

2.2 (3.92)

1.6 (4.4)

2.7 (7.5)

0.516

0.7 (3.9)

3.8 (6.2)

0.032

LVEF, median (IQR), %

55 (45–60)

55 (45–60)

60 (48.3–62)

0.48

55 (45–60)

60 (50–65)

0.102

Postprocedural LVEF improvement, mean (SD), %

2.1 (9.1)

3.3 (13.1)

0.1 (10.2)

0.075

1.1 (9)

3.9 (17.1)

0.086

Aortic valve

Peak aortic gradient, median (IQR), mmHg

11.6 (9–
–14.7)

11.6 (9–
–5.8)

10.2 (9–13)

0.164

11.6 (9–16)

11.6 (8.4–14.4)

0.62

Mean aortic gradient, mean (SD), mmHg

7.2 (2.8)

6.2 (2.1)

7.4 (2.9)

0.143

7.5 (2.7)

6.6 (2.9)

0.18

Effective orifice area, median (IQR), cm2

1.9 (1.7–2.2)

2 (1.7–2.1)

1.9 (1.7–
–2.2)

0.481

2 (1.6–2.2)

1.9 (1.8–2.2)

0.66

Effective orifice area index, median (IQR), cm2/m2

1.1 (0.9–1.4)

1.2 (0.9–
–1.5)

1.1 (0.8–
–1.4)

0.652

1.2 (0.9–1.3)

1.1 (1–1.4)

0.895

Moderate to severe PVL, n [%]

8 (11.6)

5 (9.4)

3 (18.8)

0.143

5 (11.4)

3 (12)

0.834

Mitral valve

Mitral annulus, mean (SD), mm

34 (5.9)

33.4 (7.4)

36.1 (5.4)

0.12

35.1 (5.5)

32.6 (6.9)

0.21

Peak mitral gradient, median (IQR), mmHg

5.8. (4.8–
–7.8)

5.8 (4.8–
–7.5)

9 (6.3–14.4)

0.075

5.8 (4.8–7)

5.8 (4–7.8)

0.99

Mean mitral gradient, median (IQR), mmHg

2 (1.12–3)

2 (1.1–3)

3 (2.2–4.75)

0.138

2 (1.15–
–3.25)

1.5 (1.15–3)

0.561

MR vena contracta, median (IQR), cm

0.35 (0.22–
–0.55)

0.29 (0.19–0.43)

0.61 (0.35–
–0.94)

< 0.001

0.52 (0.41–
–0.71)

0.22 (0.17–0.28)

< 0.001

MR EROA, median (IQR), cm2

0.22 (0.15–
–0.34)

0.19 (0.15–0.28)

0.36 (0.26–
–0.51)

0.001

0.33 (0.25–
–0.44)

0.16 (0.13–0.19)

< 0.001

MR regurgitant volume, median (IQR), mL

33 (19–46)

28.5 (18–44)

44 (33–66)

0.006

47 (38–63)

20 (15–28)

< 0.001

Tricuspid valve

Moderate to severe TR, n [%]

19 (27.5)

13 (24.5)

6 (37.5)

0.16

16 (36.4)

3 (12)

0.01

Pulmonary systolic artery pressure, mean (SD), mmHg

30.2 (25.2)

29.3 (24.1)

33 (29.3)

0.468

36.2 (24.8)

19.6 (22.8)

0.015

A sub-analysis comparing moderate and severe MR showed no significant differences (Tables 1–4). Severe MR was more pronounced in patients with dilated annuli (31.4 vs. 35.6mm, p = 0.02) and larger atria (27.3 vs. 31.3cm2, p = 0.04).

Secondary endpoint

The overall mortality at 3 years was 21.7%. Subjects showing MR improvement had lower mortality (8 vs. 29.55%, p = 0.047) and heart failure hospitalization rate (20 vs. 45.45%, p = 0.03) compared to those without MR reduction. However, regardless of MR improvement, patients had similar composite endpoint of all-cause mortality or heart failure hospitalization (28 vs. 50%, p = 0.078) at a 3-year follow-up (Fig. 3).

Figure 3. Kaplan-Meier curves for the secondary endpoints according to mitral regurgitation reduction at 3-year follow-up; MR — mitral regurgitation; TAVI — tran­scatheter aortic valve implantation

Discussion

In the present study, moderate or severe MR was present in about one-fourth (24.4%) of the patients undergoing TAVI and was of primary origin in more than half (56.5%) of the cases. The reduction of MR following TAVI was observed in about one-third (36.2%) of subjects, regardless of its etiology and type of bioprosthesis. In addition, persistent MR after valve implantation was not associated with worse clinical outcomes. The current findings seem to be important due to the lack of data on MR after TAVI in an unselected population with a high percentage of primary MR.

Significant MR is present in 15–20% of patients undergoing TAVI [7, 8, 15]. Few studies analyzed multiple valvular heart disease; therefore current guidelines are limited on this topic [10]. In patients with coexisting severe AS and severe MR, there is agreement that despite higher operative risk, two-valve surgery is indicated [10]. Moreover, such coexistence frequently disqualified in patients from TAVI previously [16]. Several meta-analyses showed that MR improves in approximately 50% of patients after TAVI, especially in the presence of secondary MR [7–9, 17, 18]. However, the influence of TAVI on primary MR remains unclear. Muratori and Al-Hindwan reported significant primary MR regression after TAVI [19, 20]. In contrast, Rys associated the presence of the mitral calcifications with MR worsening following TAVI [21]. In the present group, the primary MR was barely predominant and improved after TAVI, similarly to secondary MR.

Several groups tried to indicate factors predicting MR improvement [7, 8, 22–24]. In a study by Mauri, the mitral annular dimension above 32 mm predicted MR reduction [15]. Moreover, severe MR decreased more significantly than moderate in Nombela-Franco’s population [7]. In the current study, larger mitral annuli were associated with more pronounced MR. However, there was no visible trend showing mitral annular diameter to be a predictor of MR reduction. Contrary to previous reports, it was not confirmed that AV gradient, pulmonary hypertension, atrial fibrillation, or use of balloon-expandable prostheses were linked with MR recovery [7]. In addition, 11.6% of TAVI patients with significant MR reported smoking. A similar percentage (10.1%) of patients suffered from chronic obstructive pulmonary disease (COPD) and required daily use of inhalers. It was noted herein, that there was a lower likelihood of MR reduction in smokers and COPD patients.

The mechanism of MR improvement after TAVI is mainly functional and closely related to LV (left ventricular) recovery. Early MR improvement can be explained by the reduction of mitral leaflet tethering secondary to postprocedural LV afterload decline [25]. Long-term, TAVI is associated with left ventricular (LV) reverse modelling, end-diastolic volume reduction, systolic and diastolic improvement [17, 26, 27]. In contrast to previous reports, it was not confirmed that baseline LV size was associated with MR severity [7]. Instead, MR reduction was associated with postprocedural LV size reduction. Several studies have shown a positive effect of TAVI (transcatheter aortic valve implantation) on EF (ejection fraction) increase [18, 19, 26, 28]. A trend was detected towards post-TAVI EF gain in that group. Moreover, it was observed that patients responding to TAVI with MR reduction suffered noticeably less often from MI. Likely, the reverse remodeling that occurs after TAVI and leads to MR improvement does not occur in chambers affected by MI. The presence of residual perivalvular leak (PVL) is another factor that worsens MR due to LV volume overload [29]. In the present study, moderate to severe paravalvular leaks (8 subjects, 11,6%) were not related to MR intensity.

It was shown that a lack of MR reduction was associated with worse clinical outcomes, including mortality and rehospitalization rate. This is consistent with previous publications [8, 18, 19]. In addition, several papers have suggested an association between severe baseline MR and higher mortality [8, 15, 19]. Others disagreed with this association [28, 30]. However, in the present study, baseline MR severity was not associated with clinical outcomes.

Limitations

The main limitations of this study are the single-center design and its retrospective character. However, the data presented is from everyday clinical practice in a population of unselected TAVI patients.

A relatively small sample size prevented the development of a multivariable prediction model of MR reduction. A large, prospective and multicenter study would allow a more detailed evaluation.

Another limitation is the lack of quantitative measurements of MR in about third of subjects. Nevertheless, the integration of multiple parameters of MR severity allowed the evaluation of MR with high accuracy despite lacking utter quantitative data.

Conclusions

Hemodynamically significant MR improves after TAVI regardless of its etiology.

Mitral regurgitation reduction after TAVI improves clinical outcomes.

Funding: This article was supported by a fund of the Saint John Paul II Hospital, Krakow, Poland (no. FN/09/2024 to E.O.-K.).

Conflict of interest: The authors have no conflict of interest to declare.

Data availability: Data are available upon reasonable request.

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