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Cardiology Research

Original Article

Volume 12, Number 1, February 2021, pages 25-28

Predictors of Mitral Regurgitation Severity Improvement in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation

Mitral regurgitation (MR) is frequently associated with severe aortic stenosis (AS). Previous studies have demonstrated that about one-third of patients undergoing transcatheter aortic valve implantation (TAVI) for the treatment of severe AS, have at least moderate MR (MR grade ≥ 2) [1-4]. Significant MR is associated with less favorable prognosis after TAVI, including higher early and late mortality rate [4-8]. Several previous studies had conflicted results about incidence of MR improvement in patients with severe AS after TAVI procedure, with numbers ranging from 30% to 70% [4-8]. Moreover, the predictors of MR improvement after TAVI are largely unknown. As there is a worldwide acceptance of TAVI as an alternative to surgical aortic valve replacement not only in patients with high surgical risk but also in those with intermediate and low surgical risk, the ability to predict MR severity improvement before the procedure is becoming crucial. We sought to investigate whether several demographic, clinical, echocardiographic and laboratory parameters and procedure characteristics are predictive of MR severity improvement after TAVI procedure.

It was a single-center prospective cohort study based on our institutional TAVI registry. The study was approved by the Institutional Review Board and conducted in compliance with the ethical standards of the Helsinki Declaration.

Three hundred and nine (n = 309) consecutive patients with severe symptomatic AS underwent TAVI procedure in our center from July 1, 2015 till December 31, 2019. Eighty-five patients (n = 85) had concomitant significant (grade 2 or 3) MR on pre-procedure echo and were included in the analyses. The MR severity was defined either by semiquantitative (the width of vena contracta) or quantitative (the effective regurgitant orifice) analysis. Baseline clinical characteristics of the patients are described in Table 1.

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Table 1. Baseline Clinical Characteristics

We performed analysis of several echo parameters including left ventricular systolic function, left ventricular systolic and diastolic diameter, left atrial diameter and area, and left ventricular diastolic function (Table 2).

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Table 2. Descriptive Statistics of Analyzed Echo, Laboratory, Clinical Parameters and Procedure Parameters

We performed analysis of pre-procedure pro-B-type natriuretic peptide (BNP). The descriptive statistics is shown in Table 2.

We used Evolute, Sapien and Accurate Neo valves. We analyzed whether type of TAVI bioprosthesis is correlated with MR improvement. The descriptive statistics is shown in Table 2.

We analyzed whether atrial fibrillation and CHA2DS2-VASc score are correlated with MR improvement/non-improvement. The descriptive statistics is shown in Table 2.

All data were analyzed with SPSS software, Version 18.0 (SPSS Inc., Chicago, IL, USA). Categorical variables were presented as frequency (percentage) and or median ± interquartile range (IQR). Continuous variables were presented as mean ± standard deviation (SD). A Chi-square test was performed to assess the differences of 30-day and 1-year mortality in patients with improved and not improved MR. To further evaluate the independent predictors of MR, a univariable logistic regression analysis was performed. Using the backwards logistic regression model, we utilized a backwards variable elimination process. We began by assessing the statistical significance of the univariate association between each covariate and the outcome. All covariates whose univariate statistical significance was < 0.1 were forced into a multivariable model. Backwards variable elimination was then used to develop a parsimonious regression model. Those variables whose adjusted statistical significance was < 0.175 were retained in the final model. Odds ratio (OR) with a 95% confidence interval (CI) and P values were derived from the Wald Chi-square test. Sensitivity and specificity were computed for BNP using the median as the cut-point. Statistical significance was considered to be two-sided P values of < 0.05.

At baseline, before the TAVI procedure, 70 patients have moderately severe (grade 2) MR and 15 patients have severe MR (grade 3). Thirty-five patients had at least one grade improvement in severity of MR in follow-up echo performed 3 months after the procedure. None of the analyzed echo, laboratory or clinical parameters were predictive of MR severity improvement after the TAVI procedure. There was no correlation between the etiology of MR (functional vs. degenerative) or type of TAVI valve used (Table 3). The 30-day and 1-year mortality of the total TAVI cohort (n = 309) was 4.8% and 11.9%, respectively. There was no difference in 30-day (0% vs. 1.6%, P = 0.435) and 1-year (8.6% vs. 18.5%, P = 0.247) mortality in patients with improved and not improved MR.

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Table 3. Results of Logistic Regression Analysis of Possible Predictors of Post TAVI MR Severity Improvement

In this small single-center study, we demonstrated that about 40% of patients with moderate to severe MR have at least one grade improvement in the severity of the MR 3 months after TAVI. This is compatible with data in previously published studies [4-8]. We were unable to find any meaningful predictor of MR severity improvement among very broad range of clinical, echocardiographic and laboratory parameters. There was no correlation between the type of TAVI valve implanted and the MR severity improvement. This finding is contradictory to a small echocardiographic study of Giordana et al [9], which demonstrated that reduction in MR was significant in patients treated with the Edwards Sapien device but not in patients treated with the CoreValve device.

This is a small retrospective single-center study.

We were unable to find any meaningful predictor of MR severity improvement in patients with moderate to severe MR undergoing TAVI. However, there was no increased 1-year mortality in patients with not improved MR. Currently, the decision to proceed with TAVI in low or intermediate surgical risk patients with severe AS and concomitant significant MR should be made on individual basis after careful heart team discussion.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Informed Consent

Not applicable.

Authors Contributions

Alla Lubovich: substantial contribution to the conception and design of the manuscript, drafting of the manuscript and final approval of the version to be published. Fabio Kusniec: substantial contribution to the conception of the manuscript, critical revising of the manuscript and final approval of the version to be published. Doron Sudarsky: substantial contribution to the conception of the manuscript, critical revising of the manuscript and final approval of the version to be published. Liza Grossman-Rimon: analysis and interpretation of the data for the manuscript, critical revising of the manuscript and final approval of the version to be published. Shemy Carasso: substantial contribution to the conception of the manuscript, critical revising of the manuscript and final approval of the version to be published.

Data Availability

The data supporting the findings of this study are available from the corresponding author on request.

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