Transcatheter Aortic Valve Replacement and Concomitant Mitral Regurgitation

Abstract

Mitral regurgitation frequently coexists in patients with severe aortic stenosis. Patients with moderate to severe mitral regurgitation at the time of transcatheter aortic valve replacement are at increased risk of future adverse events. Whether concomitant mitral regurgitation is independently associated with worse outcomes after TAVR remains a matter of debate. The optimal therapeutic strategy in these patients-TAVR with evidence-based heart failure therapy, combined TAVR and transcatheter mitral valve intervention, or staged transcatheter therapies-is ill-defined, and guideline-based recommendations in patients at increased risk for open heart surgery are lacking. Hence, a thorough evaluation of the aortic and mitral valve anatomy and function, along with an in-depth assessment of the patients' baseline risk profile, provides the basis for an individualized treatment approach. The aim of this review is therefore to give an overview of the current literature on mitral regurgitation in TAVR, focusing on different diagnostic and therapeutic strategies and optimal clinical decision making.

Keywords: aortic stenosis; aortic valve; mitral valve; mitral valve insufficiency; mitral valve repair; transcatheter aortic vave replacement.

Figure 1

Pre- and post-procedural transesophageal echocardiography in a patient undergoing staged transcatheter aortic valve replacement (TAVR) and edge-to-edge mitral valve repair with the MitraClip® system. (A) Transesophageal color Doppler echocardiography at baseline (three-chamber view) showing severe aortic stenosis and concomitant severe mitral regurgitation. (B) Transesophageal echocardiography at baseline (aortic valve short-axis view) showing severe aortic stenosis. (C) Two-dimensional transesophageal color Doppler echocardiography (three chamber view) showing persistent severe mitral regurgitation following TAVR. (D) Two-dimensional transesophageal echocardiography (three chamber view) following TAVR. (E) Two-dimensional transesophageal color Doppler echocardiography (three-chamber view) during staged percutaneous edge-to-edge mitral valve repair with the MitraClip® system (grasping). (F) Two-dimensional transesophageal echocardiography (three-chamber view) during staged percutaneous edge-to-edge mitral valve repair with the MitraClip® system (grasping).