Impact of Multivalvular Heart Disease on Clinical Outcomes After Transcatheter Aortic Valve Implantation: Insights from the MIRA Study

C. Schulz (Hamburg)¹, A. Heinze (Hamburg)², J. Wrobel (Köln)³, I. Horn (Bad Oeynhausen)⁴, A. Scotti (New York)⁵, I. von der Heide (Hamburg)⁶, E. Girdauskas (Augsburg)⁷, S. Blankenberg (Hamburg)², L. Waldschmidt (Hamburg)⁸, N. A. Sörensen (Hamburg)⁹, A. Schäfer (Hamburg)¹⁰, N. Schofer (Hamburg)⁸, M. Keßler (Ulm)¹¹, W.-K. Kim (Gießen)¹², A. Latib (Ney York)¹³, A. Coisne (Lille)¹⁴, T. K. Rudolph (Bad Oeynhausen)¹⁵, V. Mauri (Köln)³, S. Ludwig (Hamburg)^2
1Universitäres Herz- und Gefäßzentrum Hamburg Hamburg, Deutschland; ²Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ³Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ⁴Herz- und Diabeteszentrum NRW Klinik für Kardiologie Bad Oeynhausen, Deutschland; ⁵Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care New York, USA; ⁶Universitätsklinikum Hamburg-Eppendorf Klinik für Kardiologie Hamburg, Deutschland; ⁷Universitätsklinikum Augsburg Klinik für Anästhesiologie Augsburg, Deutschland; ⁸Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland; ⁹Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Kardiologie Hamburg, Deutschland; ¹⁰Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; ¹¹Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; ¹²Universitätsklinikum Gießen und Marburg GmbH Medizinische Klinik I - Kardiologie und Angiologie Gießen, Deutschland; ¹³Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care Ney York, USA; ¹⁴Heart Valve Clinic, CHU Lille Department of Clinical Physiology and Echocardiography Lille, Frankreich; ¹⁵Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland

Background:
Multivalvular heart disease (MVHD) is frequently observed in patients undergoing transcatheter valve interventions and its presence is associated with adverse clinical outcomes. Despite its clinical relevance, the prognostic impact and echocardiographic follow-up of concomitant MVHD following transcatheter valve interventions remains insufficiently investigated. This study aimed to contribute to the evidence base by establishing an international, multi-center registry dedicated to the comprehensive evaluation of MVHD in the context of transcatheter valve therapy.

Methods:
The Multi-valve Intervention Registry and Analysis (MIRA) study is an investigator-initiated, retrospective, multi-center registry including consecutive patients with MVHD undergoing transcatheter valve interventions at 7 international centers from 2008 to 2024. Inclusion criteria comprised the presence of at least on severe valvular lesion undergoing first transcatheter interventions (aortic, mitral, or tricuspid) at baseline, and at least one other valvular lesion of at least moderate severity. This analysis focused on patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) at baseline with concomitant mitral regurgitation (MR) ≥2+ (AS+MR), concomitant tricuspid regurgitation (TR) ≥2+ (AS+TR), or combined MR ≥2+ and TR ≥II+ (AS+MR+TR). Patients with moderate or severe aortic regurgitation were excluded (Figure 1). Baseline characteristics, echocardiographic evolution of MR and TR post-intervention, and clinical outcomes out to 5 years were assessed. The primary endpoint of interest was all-cause mortality at 5-year follow-up. 
Results: Out of 5,571 patients included in the MIRA Registry, 1,940 patients with severe AS and MVHD undergoing TAVI were identified (AS+MR: n=577; AS+TR: n=302; AS+MR+TR: n=1,061. Baseline characteristics revealed a higher prevalence of atrial fibrillation, greater symptomatic severity (NYHA III/IV) and higher NT-proBNP levels in AS+MR and AS+MR+TR patients, compared to the AS+TR group. Following TAVI, concomitant MR ≥2+ improved to MR ≤1+ in 24.7% of the AS+MR group and in 15.4% of the AS+MR+TR group. Concomitant TR ≥2+ improved to TR ≤1+ in 24.8% in the AS+TR group and 20% in the AS+MR+TR group. Kaplan-Meier analysis for 5-year all-cause mortality showed highest event rates in patients with AS+MR+TR followed by patients with AS+MR. Lowest event rates were observed in patients with AS+TR (all p<0.05) (Figure 2).
 
Conclusion:
This analysis of patients with MVHD undergoing TAVI emphasizes the impact of concomitant valvular heart on clinical outcomes. In particular, highest event rates were observed in patients with concomitant MR and TR. Interestingly, in these patients both, MR and TR, showed less improvement following TAVI suggesting advanced cardiac damage and less responsiveness to AS treatment. Further analyses from this registry are ongoing.