Background
Multivalvular heart disease (MVHD) is highly prevalent among patients undergoing transcatheter valve interventions and is consistently associated with impaired clinical outcomes. However, comprehensive data on the prognostic implication in this complex population remain limited. The aim of this study was to assess outcomes of patients with MVHD undergoing transcatheter aortic valve implantation (TAVI) according to concomitant valvular heart disease.
Methods
The Multi-valve Intervention Registry and Analysis (MIRA) is an investigator-initiated, retrospective, international, multicentre registry of consecutive patients with MVHD treated at eight centres in Germany, France, and the United States between 2008 and 2024. MVHD was defined as one severe valvular lesion treated by a first transcatheter intervention and at least one additional lesion of moderate or greater severity on another heart valve. This analysis included patients undergoing TAVI for severe aortic stenosis (AS) with mitral regurgitation (MR) ≥2+ (AS+MR), tricuspid regurgitation (TR) ≥2+ (AS+TR), or both (AS+MR+TR). Changes in MR and TR and 5-year outcomes were assessed. The primary endpoint was 5-year all-cause mortality.
Results
Of 10,075 patients enrolled in MIRA, 6,805 underwent TAVI for severe AS (AS+MR: n=2,032; AS+TR: n=967; AS+MR+TR: n=3,806). Patients with AS+MR+TR had higher estimated surgical risk, more severe symptoms, and higher rates of atrial fibrillation and elevated systolic pulmonary artery pressure. Patients with AS+TR had the highest prevalence of chronic lung disease, prior myocardial infarction, and prior pacemaker implantation. After TAVI, MR improved from ≥2+ to ≤1+ in 21.9% of patients with AS+MR and 17.4% with AS+MR+TR. TR improved from ≥2+ to ≤1+ in 31.7% of patients with AS+TR and 24.2% with AS+MR+TR. Five-year all-cause mortality was significantly higher in AS+MR+TR than in AS+MR or AS+TR (66% vs. 59% and 60%, respectively; p<0.001), whereas mortality was similar between AS+MR and AS+TR (p=0.9). In multivariable Cox regression, combined MR+TR independently predicted 5-year mortality (HR 1.36, 95% CI 1.05–1.76; p=0.021). Additional predictors were higher age, atrial fibrillation, diabetes, extracardiac arteriopathy, dialysis, NYHA class ≥III, lower left ventricular ejection fraction, and lower mean aortic valve gradient.
Conclusions
This analysis of patients with MVHD undergoing TAVI highlights the impact of concomitant valvular lesions on outcomes after TAVI. The highest mortality was observed in patients with AS and combined MR and TR, with combined MR and TR independently predicting 5-year mortality. The lower rates of MR and TR improvement after TAVI may reflect advanced myocardial damage and limited reversibility. In contrast, isolated MR or TR had a similar impact on 5-year outcomes. These findings support tailored management and careful preprocedural risk stratification in patients with MVHD.
