Research progress of transcatheter aortic valve replacement in patients with coexisting moderate to severe mitral regurgitation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WEI Peijian ^1,2 , TAN Tong ^1,2 , WU Hongxiang ¹ , LIU Jian ¹ ,  GUO Huiming ¹

1. Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P. R. China;
2. Shantou University Medical College, Shantou, 515041, Guangdong, P. R. China;

Corresponding author：

GUO Huiming, Email: guohuiming@gdph.org.cn

Keywords：

Transcatheter aortic valve replacement; moderate to severe mitral regurgitation; transcatheter edge-to-edge repair; mixed valvular diseases

DOI：

10.7507/1007-4848.202107091

Video：

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After nearly two decades of application and development, the clinical efficacy of transcatheter aortic valve replacement (TAVR) has been continuously improved and demonstrated. Due to the expansion of indications of TAVR, the frequency of encountering patients with mixed valvular diseases increases greatly, particularly the moderate to severe mitral regurgitation combined with aortic stenosis. Multiple registry studies suggest that the incidence of significant mitral regurgitation is approximately 13% to 74% in patients who undergo TAVR. Some studies have reported that moderate to severe MR is associated with higher mortality, while simultaneous aortic and mitral valve surgery is associated with significantly higher surgical risk. Therefore, the optimal treatment strategy for this special patient group remains uncertain. With the further development of transcatheter therapy, staged surgery may be a feasible solution. However, there is currently a lack of evidence-based support such as randomized clinical trials. This review aims to report and evaluate relevant existing research data to help clinicians make optimal treatment decisions for this specific patient populations.

Citation： WEI Peijian, TAN Tong, WU Hongxiang, LIU Jian, GUO Huiming. Research progress of transcatheter aortic valve replacement in patients with coexisting moderate to severe mitral regurgitation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(8): 1060-1065. doi: 10.7507/1007-4848.202107091 Copy

1.	中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2019概要. 中国循环杂志, 2020, 35(9): 833-854.
2.	Beckmann A, Meyer R, Lewandowski J, et al. German heart surgery report 2019: The annual updated registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg, 2020, 68(4): 263-276.
3.	周达新, 潘文志, 吴永健, 等. 经导管主动脉瓣置换术中国专家共识 (2020更新版). 中国介入心脏病学杂志, 2020, 28(6): 301-309.
4.	Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg, 2021, 162(2): e183-e353.
5.	Miura M, Yamaji K, Shirai S, et al. Clinical impact of preprocedural moderate or severe mitral regurgitation on outcomes after transcatheter aortic valve replacement. Can J Cardiol, 2020, 36(7): 1112-1120.
6.	Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro heart survey on valvular heart disease. Eur Heart J, 2003, 24(13): 1231-1243.
7.	Lee R, Li S, Rankin JS, et al. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg, 2011, 91(3): 677-684.
8.	Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2017, 38(36): 2739-2791.
9.	潘文志, 周达新, 葛均波. 中国二尖瓣反流患者人群数量的估测. 中国胸心血管外科临床杂志, 2021, 28(5): 495-498.
10.	王墨扬, 陈阳, 叶蕴青, 等. 主动脉瓣狭窄合并冠心病患者的经导管主动脉瓣置换联合介入治疗. 内科理论与实践, 2021, 16(3): 151-154.
11.	O'Gara PT, Mack MJ. Secondary mitral regurgitation. N Engl J Med, 2020, 383(15): 1458-1467.
12.	中华医学会心血管病学分会心血管影像学组, 北京医学会心血管病学会影像学组. 中国成人心脏瓣膜病超声心动图规范化检查专家共识. 中国循环杂志, 2021, 36(2): 109-125.
13.	Vollenbroich R, Stortecky S, Praz F, et al. The impact of functional vs. degenerative mitral regurgitation on clinical outcomes among patients undergoing transcatheter aortic valve implantation. Am Heart J, 2017, 184: 71-80.
14.	Muratori M, Fusini L, Tamborini G, et al. Mitral valve regurgitation in patients undergoing TAVI: Impact of severity and etiology on clinical outcome. Int J Cardiol, 2020, 299: 228-234.
15.	Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr, 2017, 30(4): 303-371.
16.	Alper O, 谭兴, 薛澄. 左心室射血分数正常的低压差“严重”主动脉瓣狭窄. 中国胸心血管外科临床杂志, 2015, 22(8): 719-724.
17.	Freitas-Ferraz AB, Lerakis S, Barbosa Ribeiro H, et al. Mitral regurgitation in low-flow, low-gradient aortic stenosis patients undergoing TAVR: Insights from the TOPAS-TAVI registry. JACC Cardiovasc Interv, 2020, 13(5): 567-579.
18.	O'Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: A report of the American College of Cardiology Task Force on expert consensus decision pathways. J Am Coll Cardiol, 2017, 70(19): 2421-2449.
19.	中国医师协会超声分会超声心动图专业委员会, 中华医学会超声医学分会超声心动图学组, 中华医学会心血管病分会结构性心脏病学组, 等. 二尖瓣反流介入治疗的超声心动图评价中国专家共识. 中国介入心脏病学杂志, 2019, 27(1): 6-12.
20.	Khan F, Okuno T, Malebranche D, et al. Transcatheter aortic valve replacement in patients with multivalvular heart disease. JACC Cardiovasc Interv, 2020, 13(13): 1503-1514.
21.	Sannino A, Losi MA, Schiattarella GG, et al. Meta-analysis of mortality outcomes and mitral regurgitation evolution in 4, 839 patients having transcatheter aortic valve implantation for severe aortic stenosis. Am J Cardiol, 2014, 114(6): 875-882.
22.	Nombela-Franco L, Eltchaninoff H, Zahn R, et al. Clinical impact and evolution of mitral regurgitation following transcatheter aortic valve replacement: A meta-analysis. Heart, 2015, 101(17): 1395-1405.
23.	Zahn R, Gerckens U, Linke A, et al. Predictors of one-year mortality after transcatheter aortic valve implantation for severe symptomatic aortic stenosis. Am J Cardiol, 2013, 112(2): 272-279.
24.	Boerlage-van Dijk K, Wiegerinck EM, Takama T, et al. Mitral regurgitation prior to transcatheter aortic valve implantation influences survival but not symptoms. Int J Cardiol, 2016, 204: 95-100.
25.	Cortés C, Amat-Santos IJ, Nombela-Franco L, et al. Mitral regurgitation after transcatheter aortic valve replacement: Prognosis, imaging predictors, and potential management. JACC Cardiovasc Interv, 2016, 9(15): 1603-1614.
26.	Kiramijyan S, Magalhaes MA, Koifman E, et al. Impact of baseline mitral regurgitation on short- and long-term outcomes following transcatheter aortic valve replacement. Am Heart J, 2016, 178: 19-27.
27.	Gelfand EV, Hughes S, Hauser TH, et al. Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: Optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson, 2006, 8(3): 503-507.
28.	Uretsky S, Gillam L, Lang R, et al. Discordance between echocardiography and MRI in the assessment of mitral regurgitation severity: A prospective multicenter trial. J Am Coll Cardiol, 2015, 65(11): 1078-1088.
29.	Chew PG, Dobson LE, Garg P, et al. CMR quantitation of change in mitral regurgitation following transcatheter aortic valve replacement (TAVR): Impact on left ventricular reverse remodeling and outcome. Int J Cardiovasc Imaging, 2019, 35(1): 161-170.
30.	Sethi A, Kodumuri V, Prasad V, et al. Does the presence of significant mitral regurgitation prior to transcatheter aortic valve implantation for aortic stenosis impact mortality? — Meta-analysis and systematic review. Cardiology, 2020, 145(7): 428-438.
31.	Takagi H, Umemoto T, All-Literature Investigation of Cardiovascular Evidence Group. Coexisting mitral regurgitation impairs survival after transcatheter aortic valve implantation. Ann Thorac Surg, 2015, 100(6): 2270-2276.
32.	Abdelghani M, Abdel-Wahab M, Hemetsberger R, et al. Fate and long-term prognostic implications of mitral regurgitation in patients undergoing transcatheter aortic valve replacement. Int J Cardiol, 2019, 288: 39-43.
33.	Mavromatis K, Thourani VH, Stebbins A, et al. Transcatheter aortic valve replacement in patients with aortic stenosis and mitral regurgitation. Ann Thorac Surg, 2017, 104(6): 1977-1985.
34.	Feldt K, De Palma R, Bjursten H, et al. Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement. Int J Cardiol, 2019, 294: 32-36.
35.	Witberg G, Codner P, Landes U, et al. Effect of transcatheter aortic valve replacement on concomitant mitral regurgitation and its impact on mortality. JACC Cardiovasc Interv, 2021, 14(11): 1181-1192.
36.	Witberg G, Codner P, Landes U, et al. Transcatheter treatment of residual significant mitral regurgitation following TAVR: A multicenter registry. JACC Cardiovasc Interv, 2020, 13(23): 2782-2791.
37.	Chiche O, Rodés-Cabau J, Campelo-Parada F, et al. Significant mitral regurgitation in patients undergoing TAVR: Mechanisms and imaging variables associated with improvement. Echocardiography, 2019, 36(4): 722-731.
38.	Mauri V, Körber MI, Kuhn E, et al. Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement. Clin Res Cardiol, 2020, 109(10): 1261-1270.
39.	Voisine E, Beaupré F, O'Connor K, et al. Prognosis of functional mitral regurgitation after aortic valve replacement for pure severe aortic stenosis. J Card Surg, 2021, 36(9): 3100-3111.

1. 中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2019概要. 中国循环杂志, 2020, 35(9): 833-854.
2. Beckmann A, Meyer R, Lewandowski J, et al. German heart surgery report 2019: The annual updated registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg, 2020, 68(4): 263-276.
3. 周达新, 潘文志, 吴永健, 等. 经导管主动脉瓣置换术中国专家共识 (2020更新版). 中国介入心脏病学杂志, 2020, 28(6): 301-309.
4. Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg, 2021, 162(2): e183-e353.
5. Miura M, Yamaji K, Shirai S, et al. Clinical impact of preprocedural moderate or severe mitral regurgitation on outcomes after transcatheter aortic valve replacement. Can J Cardiol, 2020, 36(7): 1112-1120.
6. Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro heart survey on valvular heart disease. Eur Heart J, 2003, 24(13): 1231-1243.
7. Lee R, Li S, Rankin JS, et al. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg, 2011, 91(3): 677-684.
8. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2017, 38(36): 2739-2791.
9. 潘文志, 周达新, 葛均波. 中国二尖瓣反流患者人群数量的估测. 中国胸心血管外科临床杂志, 2021, 28(5): 495-498.
10. 王墨扬, 陈阳, 叶蕴青, 等. 主动脉瓣狭窄合并冠心病患者的经导管主动脉瓣置换联合介入治疗. 内科理论与实践, 2021, 16(3): 151-154.
11. O'Gara PT, Mack MJ. Secondary mitral regurgitation. N Engl J Med, 2020, 383(15): 1458-1467.
12. 中华医学会心血管病学分会心血管影像学组, 北京医学会心血管病学会影像学组. 中国成人心脏瓣膜病超声心动图规范化检查专家共识. 中国循环杂志, 2021, 36(2): 109-125.
13. Vollenbroich R, Stortecky S, Praz F, et al. The impact of functional vs. degenerative mitral regurgitation on clinical outcomes among patients undergoing transcatheter aortic valve implantation. Am Heart J, 2017, 184: 71-80.
14. Muratori M, Fusini L, Tamborini G, et al. Mitral valve regurgitation in patients undergoing TAVI: Impact of severity and etiology on clinical outcome. Int J Cardiol, 2020, 299: 228-234.
15. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr, 2017, 30(4): 303-371.
16. Alper O, 谭兴, 薛澄. 左心室射血分数正常的低压差“严重”主动脉瓣狭窄. 中国胸心血管外科临床杂志, 2015, 22(8): 719-724.
17. Freitas-Ferraz AB, Lerakis S, Barbosa Ribeiro H, et al. Mitral regurgitation in low-flow, low-gradient aortic stenosis patients undergoing TAVR: Insights from the TOPAS-TAVI registry. JACC Cardiovasc Interv, 2020, 13(5): 567-579.
18. O'Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: A report of the American College of Cardiology Task Force on expert consensus decision pathways. J Am Coll Cardiol, 2017, 70(19): 2421-2449.
19. 中国医师协会超声分会超声心动图专业委员会, 中华医学会超声医学分会超声心动图学组, 中华医学会心血管病分会结构性心脏病学组, 等. 二尖瓣反流介入治疗的超声心动图评价中国专家共识. 中国介入心脏病学杂志, 2019, 27(1): 6-12.
20. Khan F, Okuno T, Malebranche D, et al. Transcatheter aortic valve replacement in patients with multivalvular heart disease. JACC Cardiovasc Interv, 2020, 13(13): 1503-1514.
21. Sannino A, Losi MA, Schiattarella GG, et al. Meta-analysis of mortality outcomes and mitral regurgitation evolution in 4, 839 patients having transcatheter aortic valve implantation for severe aortic stenosis. Am J Cardiol, 2014, 114(6): 875-882.
22. Nombela-Franco L, Eltchaninoff H, Zahn R, et al. Clinical impact and evolution of mitral regurgitation following transcatheter aortic valve replacement: A meta-analysis. Heart, 2015, 101(17): 1395-1405.
23. Zahn R, Gerckens U, Linke A, et al. Predictors of one-year mortality after transcatheter aortic valve implantation for severe symptomatic aortic stenosis. Am J Cardiol, 2013, 112(2): 272-279.
24. Boerlage-van Dijk K, Wiegerinck EM, Takama T, et al. Mitral regurgitation prior to transcatheter aortic valve implantation influences survival but not symptoms. Int J Cardiol, 2016, 204: 95-100.
25. Cortés C, Amat-Santos IJ, Nombela-Franco L, et al. Mitral regurgitation after transcatheter aortic valve replacement: Prognosis, imaging predictors, and potential management. JACC Cardiovasc Interv, 2016, 9(15): 1603-1614.
26. Kiramijyan S, Magalhaes MA, Koifman E, et al. Impact of baseline mitral regurgitation on short- and long-term outcomes following transcatheter aortic valve replacement. Am Heart J, 2016, 178: 19-27.
27. Gelfand EV, Hughes S, Hauser TH, et al. Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: Optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson, 2006, 8(3): 503-507.
28. Uretsky S, Gillam L, Lang R, et al. Discordance between echocardiography and MRI in the assessment of mitral regurgitation severity: A prospective multicenter trial. J Am Coll Cardiol, 2015, 65(11): 1078-1088.
29. Chew PG, Dobson LE, Garg P, et al. CMR quantitation of change in mitral regurgitation following transcatheter aortic valve replacement (TAVR): Impact on left ventricular reverse remodeling and outcome. Int J Cardiovasc Imaging, 2019, 35(1): 161-170.
30. Sethi A, Kodumuri V, Prasad V, et al. Does the presence of significant mitral regurgitation prior to transcatheter aortic valve implantation for aortic stenosis impact mortality? — Meta-analysis and systematic review. Cardiology, 2020, 145(7): 428-438.
31. Takagi H, Umemoto T, All-Literature Investigation of Cardiovascular Evidence Group. Coexisting mitral regurgitation impairs survival after transcatheter aortic valve implantation. Ann Thorac Surg, 2015, 100(6): 2270-2276.
32. Abdelghani M, Abdel-Wahab M, Hemetsberger R, et al. Fate and long-term prognostic implications of mitral regurgitation in patients undergoing transcatheter aortic valve replacement. Int J Cardiol, 2019, 288: 39-43.
33. Mavromatis K, Thourani VH, Stebbins A, et al. Transcatheter aortic valve replacement in patients with aortic stenosis and mitral regurgitation. Ann Thorac Surg, 2017, 104(6): 1977-1985.
34. Feldt K, De Palma R, Bjursten H, et al. Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement. Int J Cardiol, 2019, 294: 32-36.
35. Witberg G, Codner P, Landes U, et al. Effect of transcatheter aortic valve replacement on concomitant mitral regurgitation and its impact on mortality. JACC Cardiovasc Interv, 2021, 14(11): 1181-1192.
36. Witberg G, Codner P, Landes U, et al. Transcatheter treatment of residual significant mitral regurgitation following TAVR: A multicenter registry. JACC Cardiovasc Interv, 2020, 13(23): 2782-2791.
37. Chiche O, Rodés-Cabau J, Campelo-Parada F, et al. Significant mitral regurgitation in patients undergoing TAVR: Mechanisms and imaging variables associated with improvement. Echocardiography, 2019, 36(4): 722-731.
38. Mauri V, Körber MI, Kuhn E, et al. Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement. Clin Res Cardiol, 2020, 109(10): 1261-1270.
39. Voisine E, Beaupré F, O'Connor K, et al. Prognosis of functional mitral regurgitation after aortic valve replacement for pure severe aortic stenosis. J Card Surg, 2021, 36(9): 3100-3111.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Research progress of transcatheter aortic valve replacement in patients with coexisting moderate to severe mitral regurgitation

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