Author + information
- Received August 12, 2019
- Revision received October 11, 2019
- Accepted November 15, 2019
- Published online March 2, 2020.
- Afonso B. Freitas-Ferraz, MDa,
- Stamatios Lerakis, MDb,
- Henrique Barbosa Ribeiro, MD, PhDa,
- Martine Gilard, MDc,
- João L. Cavalcante, MDd,
- Raj Makkar, MDe,
- Howard C. Herrmann, MDf,
- Stephan Windecker, MDg,
- Maurice Enriquez-Sarano, MDh,
- Asim N. Cheema, MDi,
- Luis Nombela-Franco, MD, PhDj,
- Ignacio Amat-Santos, MD, PhDk,
- Antonio J. Muñoz-García, MD, PhDl,
- Bruno Garcia del Blanco, MDm,
- Alan Zajarias, MDn,
- John C. Lisko, MDb,
- Salim Hayek, MDb,
- Vasilis Babaliaros, MDb,
- Florent Le Ven, MDc,
- Thomas G. Gleason, MDd,
- Tarun Chakravarty, MDe,
- Wilson Y. Szeto, MDf,
- Marie-Annick Clavel, DVM, PhDa,h,
- Alberto de Agustin, MD, PhDj,
- Vicenç Serra, MDm,
- John T. Schindler, MDd,
- Abdellaziz Dahou, MD, MSca,
- Mohamed-Salah Annabi, MDa,
- Emilie Pelletier-Beaumont, MSca,
- Philippe Pibarot, DVM, PhDa and
- Josep Rodés-Cabau, MDa,∗ ()
- aQuebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
- bEmory University Hospital, Atlanta, Georgia
- cCHU Brest, Brest, France
- dUniversity of Pittsburgh/UPMC, Pittsburgh, Pennsylvania
- eCedars Sinai Hospital, Los Angeles, California
- fUniversity of Pennsylvania Medical Center, Philadelphia, Pennsylvania
- gBern University Hospital, Bern, Switzerland
- hMayo Clinic, Rochester, Minnesota
- iSt Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- jHospital Clínico San Carlos - Madrid, Madrid, Spain
- kHospital Clinico Universitario de Valladolid, Valladolid, Spain
- lHospital Virgen de la Victoria, Malaga, Spain
- mHospital Universitari Vall d'Hebron, Barcelona, Spain
- nWashington University School of Medicine, St. Louis, Missouri
- ↵∗Address for correspondence:
Dr. Josep Rodés-Cabau, Quebec Heart & Lung Institute, Laval University, 2725 Chemin Ste-Foy, G1V 4G5 Quebec City, Quebec, Canada.
Objectives This study sought to determine the incidence, clinical impact, and changes over time of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR).
Background Few data exist on the clinical impact and changes in severity over time of MR in patients with LFLG-AS undergoing TAVR.
Methods A total of 308 TAVR candidates with LFLG-AS were included. Patients were categorized according to MR severity at baseline, and presence of MR improvement at 12-month follow-up. Clinical outcomes were assessed at 1 and 12 months (+ echocardiography), and yearly thereafter.
Results Baseline mild and moderate-to-severe MR were present in 118 (38.3%) and 115 (37.3%) patients, respectively. MR was of functional and mixed etiology in 77.2% and 22.7% of patients, respectively. A total of 131 patients (42.5%) died after a median follow-up of 2 (1 to 3) years. Baseline moderate-or-greater MR had no impact on mortality (hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 0.72 to 2.48) or heart failure hospitalization (HR: 1.02; 95% CI: 0.49 to 2.10). At 1-year follow-up, MR improved in 44.3% of patients and remained unchanged/worsened in 55.7%. The lack of MR improvement was associated with a higher risk of all-cause and cardiac mortality (HR: 2.02; 95% CI: 1.29 to 3.17; HR: 3.03; 95% CI: 1.27 to 7.23, respectively), rehospitalization for cardiac causes (HR: 1.50; 95% CI: 1.04 to 2.15), and an increased overall-mortality/heart failure rehospitalization (HR: 1.94; 95% CI: 1.25 to 3.02). A higher baseline left ventricular end-diastolic diameter and a higher increase in left ventricular ejection fraction were found to be independent predictors of MR improvement at 1-year follow-up (odds ratio: 0.69; 95% CI: 0.51 to 0.94; and odds ratio: 0.81; 95% CI: 0.67 to 0.96, respectively).
Conclusions Most TAVR candidates with LFLG-AS had some degree of MR, of functional origin in most cases. MR improved in about one-half of patients, with larger left ventricular size and a higher increase in left ventricular ejection fraction post-TAVR determining MR improvement over time. The lack of MR improvement at 1 year was associated with poorer outcomes.
- low-flow low-gradient aortic stenosis
- mitral regurgitation
- reduced left ventricular ejection fraction
- transcatheter aortic valve replacement
This study was supported by a grant from the Canadian Institute of Health Research (FDN-143225). Dr. Freitas-Ferraz was supported by a research grant from the Quebec Heart & Lung Institute Foundation. Dr. Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Disease Interventions. Dr. Pibarot holds de Canada Research Chair in Valvular Heart Diseases. Dr. Ribeiro has received a research grant from CNPq, Conselho Nacional de Desenvolvimento Científico e Tecnológico–Brasil. Dr. Cavalcante is consultant for and has received research grants from Edwards Lifesciences, Medtronic, and Abbott Vascular; and is consultant for Boston Scientific and Siemens Healthineers. Dr. Makkar has received grants from Abbott and Edwards Lifesciences during the conduct of the study; and has received other payments from Cordis, Medtronic, and Cedars-Sinai Medical Center outside the submitted work. Dr. Herrmann has received research grants from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic; has received consultant fees from Edwards Lifesciences and Medtronic; and has received grants from University of Laval during the conduct of the study. Dr. Windecker has received research contracts to the institution from Bracco, Boston Scientific, Terumo, Edwards Lifesciences, and Medtronic; and has received grants from Abbott, Amgen, Bayer, Bristol-Myers Squibb, Edwards Lifesciences, Biotronik, Boston Scientific, Medtronic, St. Jude Medical, Sinomed, Polares, and Terumo outside the submitted work. Dr. Enriquez-Sarano has received grants from Edwards LLC during the conduct of the study. Dr. Nombela-Franco served as a proctor for Abbott; and has received speaker honoraria from Edwards Lifesciences Inc. Dr. Babaliaros has equity in Transmural Systems; and has received personal fees from Edwards Lifesciences and Abbott Vascular outside the submitted work. Dr. Gleason is a Medical Advisory Board member for Abbott; has received grants from Medtronic; and has received other payments from Boston Scientific and Abbott outside the submitted work. Dr. Chakravarty has received payments from Edwards Lifesciences, Medtronic Inc., and Boston Scientific during the conduct of the study. Dr. Szeto has received payments from Edwards Lifesciences and Medtronic during the conduct of the study. Dr. Clavel has a core laboratory contract with Edwards Lifesciences without direct compensation; and has received a research grant with Medtronic. Dr. Schindler has received payments from Boston Scientific outside the submitted work; and is a proctor for Edwards Lifesciences. Dr. Pibarot has core lab contracts with Edwards Lifesciences for which he receives no direct compensation; and has received grants from Edwards Lifesciences and Medtronic during the conduct of the study, and Cardiac Phoenix and V-Wave Ltd. outside the submitted work. Dr. Rodés-Cabau has received institutional research grants from Edwards Lifesciences, Medtronic, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 12, 2019.
- Revision received October 11, 2019.
- Accepted November 15, 2019.
- 2020 American College of Cardiology Foundation
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