https://doi.org/10.1007/s00392-025-02625-4
1Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; 2Universitätsklinikum Bonn Klinik und Poliklinik für Herzchirurgie Bonn, Deutschland
BACKGROUND
Multivalvular heart disease (MVHD) is prevalent among patients with severe aortic stenosis (AS), with tricuspid regurgitation (TR) being a common coexisting condition that compounds morbidity and mortality risks. Traditional management has involved combined surgical aortic valve replacement (SAVR) and tricuspid valve repair (TVR), which, while effective, is associated with increased surgical risk and prolonged recovery times. With advances in less invasive techniques, transcatheter aortic valve replacement (TAVR) has emerged as a viable alternative for AS patients. Additionally, the significant evolution of transcatheter edge-to-edge repair (TEER) offers a promising option for managing TR. However, comparative data on the outcomes of combined SAVR and TVR versus TAVR with staged TEER in this patient population remain limited.
OBJECTIVE
The study aimed evaluate and compare the echocardiographic and clinical outcomes of patients with severe AS and TR undergoing combined SAVR with TVR versus those undergoing TAVR followed by staged TEER.
METHODS
This retrospective study included 69 patients with severe AS and TR treated at the Heart Center Bonn between 2011 and 2023. Of these, 32 (46.3%) patients underwent combined SAVR with TVR, while 37 (53.6%) patients received a TAVR followed by staged TEER. All patients underwent comprehensive echocardiographic evaluations both prior to the valvular intervention and before discharge. The clinical endpoints included 30-day and one-year all-cause mortality following valvular intervention, as well as VARC-3-defined complications at 30 days.
RESULTS
The study population had a mean age of 74.7±9.8 years, with 46.4% being female. The average EuroSCORE II was 7.0±4.7 %, indicating an intermediate surgical risk profile of the overall cohort. Patients undergoing SAVR with TVR were significantly younger compared to those who underwent TAVR followed by staged TEER (67.7±9.3 years vs. 80.8±5.1 years, p<0.01). Moreover, the SAVR group had a lower surgical risk (EuroSCORE II 5.7±2.6 % vs. 8.1±5.7 %, p=0.02). The mean left ventricular ejection fraction was 51.3±13.1 %, with no significant difference between the two groups (p=0.28). Echocardiographic evaluations revealed favorable outcomes across the overall cohort, with 81.2% of patients having no or only mild residual TR. Moderate residual TR was more frequently observed in patients undergoing staged TEER compared to those receiving surgical tricuspid repair (24% vs. 9.4%), though this difference did not reach statistical significance (p=0.12). VARC-3-defined complications were comparable between the SAVR and TAVR group, including acute kidney injury (15.6% vs. 5.4%, p=0.43), new pacemaker implantation (6.3% vs. 8.1%, p=1.0), and myocardial infarction (0% vs. 0%, p=1.0). The 30-day all-cause mortality rate was significantly higher in the SAVR with TVR group compared to the TAVR followed by staged TEER group (15.6% vs. 2.7%, p=0.047), Figure 1A. However, the one-year all-cause mortality rates were comparable between both groups (21.9% vs. 13.5%, p=0.19), Figure 1B.
CONCLUSION
In selected patients with severe AS and concomitant TR, TAVR followed by staged TEER offers comparable clinical and echocardiographic outcomes to combined SAVR with TVR, despite the TAVR group being older and at higher surgical risk. Further prospective studies are warranted to confirm these results and to guide clinical decision-making for optimal management strategies in MVHD.