Development of de novo atrioventricular Valve Regurgitation after Transcatheter Aortic Valve Replacement

Introduction  

Concomitant atrioventricular valve regurgitation in patients with severe aortic stenosis (AS) has been described as a consequence of pressure overload with damage of the left ventricle, pulmonary hypertension and right heart dysfunction and therefore reflecting an advanced disease state. On the other hand, patients undergoing transcatheter aortic valve replacement (TAVR) due to severe AS but without concomitant mitral (MR) and/or tricuspid regurgitation (TR) are characterized mainly as stage 0 or stage 1, representing less cardiac damage following severe AS.¹ TAVR and therefore treatment of the underlying pathology with reduction of pressure overload might lead to the assumption that atrioventricular valve regurgitation is not supposed to develop after the procedure. However, this phenomenon can be observed in daily routine, but data about prevalence, risk factors and outcomes in these patients is scarce. 

Purpose

The aim of the study was to identify and characterize patients at risk of developing atrioventricular valve regurgitation despite treating aortic valve disease with TAVR.  

Methods

We retrospectively analyzed patients undergoing TAVR for severe aortic stenosis at Munich University Hospital between January 2016 and December 2021. Patients with prior aortic valve bioprosthesis, concomitant MR and/or TR ≥ grade II and TAVR for aortic valve regurgitation were excluded from the study. Moreover, insufficient imaging insufficient imaging quality led to exclusion to ensure standardized assessment of echocardiographic data.

Results 

Between January 2016 and December 2021 3,153 received TAVR for severe aortic valve disease at Munich University Hospital. After exclusion of 1,127 patients, mainly due to concomitant MR and/or TR ≥ grade II at baseline, 2,026 patients were eligible for the study. Echocardiographic follow-up at least 45 days after the procedure was available for 1,034 patients. Of these, 102 (9.9 %) developed atrioventricular valve regurgitation ≥ grade II. While 56 patients experienced combined MR and TR, 36 patients exhibited isolated MR and 10 patients isolated TR (Figure 1). 

Patients who developed atrioventricular valve regurgitation after TAVR showed significantly higher 3-year all-cause mortality rates (corresponding hazard ratio: 1.71; 95 % CI: 1.08 – 2.69, p = 0.02, Figure 2).

Conclusion 

In patients undergoing TAVR for severe aortic stenosis and without concomitant MR and/or TR, 9.9 % developed significant aortic valve regurgitation after the procedure despite reduction of pressure overload. Moreover, these patients showed significantly higher 3-year all-cause mortality rates compared to patients without concomitant MR and/or TR. 

1. Généreux P, Pibarot P, Redfors B, et al. Staging classification of aortic stenosis based on the extent of cardiac damage. European Heart Journal. 2017;38(45):3351-3358. doi:10.1093/eurheartj/ehx381