TAVR for patients with multivalvular disease

Improvement of mitral regurgitation

Elderly patients who develop important calcific aortic stenosis, present with several comorbidities and often develop multivalvar disease. The deposition of calcium in the mitral annulus can cause regurgitant dysfunction or even in the presence of a myxomatous degeneration that generates an advanced reflux.

Given this, would the presence of an organic mitral regurgitation of high degrees contraindicate the isolated percutaneous treatment of aortic stenosis?

Mitral regurgitation (MR), which is commonly associated with AS, can present a prevalence of up to 74% in this population. World literature data show that approximately 15% of patients undergoing TAVR have significant MR, with some studies showing an important negative prognosis in this group of patients.

Several studies, including our research group at the Dante Pazzanese Cardiology Institute, show that percutaneous treatment of aortic stenosis improves the degree of primary mitral regurgitation. The reasons for this are physiological, because by suddenly improving the afterload that the left ventricle has to deal with, we see a drop in intraventricular systolic pressure that leads to less mitral regurgitation.

Another situation is the ventricular remodeling that occurs after the implantation of the TAVR, with improvement in the contractile performance and systolic dynamics, improving the functioning of the mitral valve complex and making the system more competent.

Obviously, advanced degrees of valve degeneration do not completely regress with the isolated treatment of the aortic valve, but they probably show some degree of improvement in regurgitant volume.

What is the most appropriate reading of this finding? The presence of mitral regurgitation in a patient at high surgical risk should not contraindicate percutaneous treatment of the mitral valve, as up to 66% of cases regress substantially. Other classic comorbidities such as COPD, extensive presence of fibrosis, etc. turn on a yellow light in the cardiologist, but mitral regurgitation, so far, should not inspire greater concerns in the indication.

Suggested literature:

1 – Florentino TM, Bihan DL, Abizaid AAC, et al. Primary Mitral Valve Regurgitation Outcome in Patients With Severe Aortic Stenosis 1 Year After Transcatheter Aortic Valve Implantation: Echocardiographic Evaluation. Arq Bras Cardiol. 2017 Jul 10:0.

 

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