1Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; 2Kreiskrankenhaus Waldbröl GmbH Klinik für Innere Medizin, Kardiologie Waldbröl, Deutschland; 3Universitätsklinikum Düsseldorf Klinik für Kardiologie, Pneumologie und Angiologie Düsseldorf, Deutschland
BACKGROUND
Multivalvular Heart Disease (VHD) is prevalent among patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Previous studies reported increased one-year mortality rates in TAVR patients with concomitant mitral regurgitation (MR) as well as tricuspid regurgitation (TR). However, the long-term impact of VHD on outcomes in patients undergoing TAVR remains unclear. Moreover, existing studies investigating additional VHD focus on concomitant MR or TR, lacking head-to-head comparisons of different VHD. Additionally, whether staged transcatheter valvular intervention for concomitant VHD improve outcomes in these patients remains unknown.
OBJECTIVE
The study aimed to comprehensively evaluate the incidence of VHD in a contemporary TAVR cohort. Specifically, we sought to assess and compare the impact of concomitant severe MR and TR on outcomes at one and five years following TAVR, and to examine the impact of a staged edge-to-edge valvular intervention for concomitant VHD.
METHODS
The study cohort included 2934 consecutive patients with severe AS undergoing TAVR with next generation transcatheter heart valves between January 2015 and December 2022 at the Heart Center Bonn. All patients have been screened for additional staged valvular intervention for severe MR or TR. Additionally, TAVR patients from the Heart Centers Düsseldorf and Dortmund, who met the criteria for VHD and underwent staged valvular intervention (n=70) have been included. Clinical endpoints included one- and five-year all-cause mortality post-TAVR.
RESULTS
The mean age of our study population was 80.9±6.4 years, with 45.9% being female. A concomitant severe VHD was observed in 357 (12.2%) patients undergoing TAVR, of whom 168 (5.7%) had a severe TR and 189 (6.5%) had a severe MR. A moderate VHD was seen 876 (29.9%) patients. An additional staged edge-to-edge valvular intervention was performed in 59 (2.0%) and 147 (5.0%) patients due to severe TR and MR, respectively. The overall one- and five-year all-cause mortality rates were 8.9% and 23.3% following TAVR. The one-year all-cause mortality was significantly higher in patients with a concomitant severe VHD (14.8%) as compared to patients with mild/no VHD (6.5%, p<0.01). Notably, the highest one-year mortality was observed in patients with a concomitant severe TR (17.2%), followed by patients with a severe MR (12.7%) and mild/no VHD (6.5%, p<0.01), Figure 1A. This difference persisted for up to five years after TAVR (p<0.01), as shown in Figure 2A. An additional staged edge-to-edge valvular intervention was associated with decreased one-year mortality rate as compared to patients with a persistent severe VHD (8.25% vs 14.8%, p<0.01, Figure 1B). This association remained over the five-year follow-up period (p<0.01), as shown in Figure 2B. Multivariate regression analyses revealed that a concomitant severe TR (OR: 1.54 [95% CI: 1.10–2.25], p=0.02) was independently associated with the mortality following TAVR.
CONCLUSION
The presence of a severe concomitant VHD was associated with an increased one- and five-year mortality in patients with AS undergoing TAVR. In this context, severe TR appeared to be associated with a higher mortality compared to severe MR. The potential benefit of a staged edge-to-edge valvular intervention for concomitant VHD should be carefully considered as it shows promise in improving outcomes, especially for patients with persistent severe VHD post-TAVR.