Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation

ABSTRACT

Introduction

Significant mitral regurgitation (MR) frequently coexists in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). These patients have worse clinical outcomes than those with non-significant MR, especially if MR persists after treatment of the aortic stenosis. The optimal treatment approach for this challenging high-risk population is not well defined.

Areas Covered

This review aims to present the current literature on concomitant significant MR in the TAVR population, and to provide a comprehensive algorithmic approach for clinical decision-making in this challenging cohort of patients.

Expert opinion

Concomitant mitral and aortic valve disease is a complex clinical entity. An exhaustive and comprehensive assessment of patient’s clinical characteristics and mitral valve anatomy and function is required in order to assess the surgical risk, predict the MR response after AVR and evaluate the feasibility of percutaneous MV treatment if necessary. Further developments in transcatheter techniques will expand the indications for double valve treatment in operable and inoperable patients with concomitant significant MR and aortic stenosis.

KEYWORDS:

• Aortic stenosis
• mitral regurgitation
• transcatheter aortic valve replacement
• TAVR
• TAVI
• multivalvular heart disease

Article highlights

• The prevalence of moderate-to-severe MR in intermediate to high surgical risk patients with severe aortic stenosis undergoing TAVR is ~25%.

• Significant MR has been associated with a negative clinical impact on both short and long-term outcomes.

• Improvement in mitral regurgitation occurs in approximately 50% of patients after TAVR, with a resulting positive impact on clinical outcomes.

• The main predictors of MR improvement post TAVR are the absence of degenerative disease of the MV apparatus, and the secondary MR.

• Exhaustive assessment of MR severity and mechanism, as a well as the patient’s clinical characteristics and the surgical risk is mandatory when deciding the optimal treatment strategy.

• A minimally invasive approach with transcatheter aortic and mitral valve interventions, manly in a staged fashion, is a feasible strategy in selected patients and should be considered in high surgical risk or inoperable patients with favorable anatomical characteristics.

Declaration of interest

L Nombela-Franco has served as a proctor for Abbott and received speaker honoraria from Edwards Lifesciences, Inc. JA de Agustin has served as a proctor for Abbott. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosure

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.