TAVI in Patients with Mitral Annular Calcification and/or Mitral Stenosis

Abstract

Background We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI).

Methods Between 11/2009 and 06/2017, 1,058 patients underwent TAVI in the presence of concomitant MAC or MS at our center. Subgroups were built and multivariate logistic regression, COX regression, Kaplan–Meier survival analyses, and receiver operating characteristics method were performed.

Results Thirty-day mortality was 7.5% (79/1,058) with highest mortality in patients severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 72.7%; p < 0.001). Moderate-to-severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94–16.26, p < 0.001), impaired left ventricular ejection fraction (OR: 1.38, CI: 1.10–1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11–1.67, p < 0.01) were predictive of 30-day survival. Left ventricular systolic/end-diastolic pressure drop of <59.5 mm Hg / <19.5 mm Hg was associated with increased mortality.

Conclusions TAVI in the presence of MAC and mild MS is associated with acceptable acute outcomes but should be considered high-risk procedures in patients with moderate and especially those with severe MS. Our results suggest adverse hemodynamics after TAVI with concomitant MS, which may be caused by underfilling of the left ventricle leading to low-cardiac output.

Keywords

transcatheter aortic valve implantation - mitral stenosis - aortic valve - mitral valve - aortic valve stenosis

Author Contributions

Andreas Schaefer made substantial contributions to the conception and design of the work; to the acquisition, analysis, and interpretation of data for the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Harun Sarwari made substantial contributions to the conception and design of the work; to the acquisition of data for the work; to drafting the work; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Niklas Schofer made substantial contributions to the conception and design of the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Yvonne Schneeberger made substantial contributions to the conception and design of the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Dirk Westermann made substantial contributions to the conception and design of the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Gerhard Schoen made substantial contributions to the conception and design of the work; to the acquisition, analysis, and interpretation of data for the work, to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Stefan Blankenberg made substantial contributions to the conception and design of the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Hermann Reichenspurner made substantial contributions to the conception and design of the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ulrich Schäfer made substantial contributions to the conception and design of the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Lenard Conradi made substantial contributions to the conception and design of the work; to the acquisition, analysis, and interpretation of data for the work; to drafting the work and revising it critically for important intellectual content; to final approval of the version to be published; and agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosure Statement

A. Schaefer has received travel compensation from Symetis SA and Abbott Vascular Inc.

U. Schaefer is a proctor for Symetis SA and Medtronic, is a consultant to Medtronic and Symetis SA, and has received lecture fees from Medtronic.

L. Conradi is a proctor for Boston Scientific and Medtronic and proctor and consultant for Edwards Lifesciences.

All others authors have nothing to disclose.

Publikationsverlauf

Eingereicht: 10. August 2019

Angenommen: 19. November 2019

Artikel online veröffentlicht:
01. März 2020

• References

• 1 Baumgartner H, Falk V, Bax JJ. et al; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38 (36) 2739-2791
• 2 Nishimura RA, Otto CM, Bonow RO. et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017; 70 (02) 252-289
• 3 Leon MB, Smith CR, Mack MJ. et al; PARTNER 2 Investigators. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016; 374 (17) 1609-1620
• 4 Reardon MJ, Van Mieghem NM, Popma JJ. et al; SURTAVI Investigators. SURTAVI Investigators. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med 2017; 376 (14) 1321-1331
• 5 Regev E, Finkelstein A, Assali A. et al. Comparison of outcome of transcatheter aortic valve implantation for severe aortic stenosis in 3 age groups (≤70; 71 to 80, and ≥81 years). Am J Cardiol 2017; 120 (09) 1607-1611
• 6 Doshi R, Shlofmitz E, Meraj P. Comparison of outcomes and complications of transcatheter aortic valve implantation in women versus men (from the National Inpatient Sample). Am J Cardiol 2018; 121 (01) 73-77
• 7 Anand A, Harley C, Visvanathan A. et al. The relationship between preoperative frailty and outcomes following transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur Heart J Qual Care Clin Outcomes 2017; 3 (02) 123-132
• 8 Levi A, Codner P, Masalha A. et al. Predictors of 1-year mortality after transcatheter aortic valve implantation in patients with and without advanced chronic kidney disease. Am J Cardiol 2017; 120 (11) 2025-2030
• 9 Schaefer A, Neumann N, Linder M. et al. Outcomes with a latest generation self-expandable, intra-annular, re-sheathable transcatheter heart valve system: analysis of patients with impaired left ventricular function and determinants for pacemaker implantation. Clin Res Cardiol 2018; 107 (10) 914-923
• 10 Schofer N, Deuschl F, Schön G. et al. Comparative analysis of balloon- versus mechanically-expandable transcatheter heart valves considering landing zone calcification. J Cardiol 2018; 71 (06) 540-546
• 11 Abramowitz Y, Kazuno Y, Chakravarty T. et al. Concomitant mitral annular calcification and severe aortic stenosis: prevalence, characteristics and outcome following transcatheter aortic valve replacement. Eur Heart J 2017; 38 (16) 1194-1203
• 12 Ancona MB, Giannini F, Mangieri A. et al. Impact of mitral annular calcium on outcomes after transcatheter aortic valve implantation. Am J Cardiol 2017; 120 (12) 2233-2240
• 13 Nishimura RA, Vahanian A, Eleid MF, Mack MJ. Mitral valve disease--current management and future challenges. Lancet 2016; 387 (10025): 1324-1334
• 14 Unger P, Lancellotti P, de Cannière D. The clinical challenge of concomitant aortic and mitral valve stenosis. Acta Cardiol 2016; 71 (01) 3-6
• 15 Carabello BA. Modern management of mitral stenosis. Circulation 2005; 112 (03) 432-437
• 16 Kappetein AP, Head SJ, Généreux P. et al; Valve Academic Research Consortium (VARC)-2. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document (VARC-2). Eur J Cardiothorac Surg 2012; 42 (05) S45-S60
• 17 Schaefer A, Treede H, Schoen G. et al. Improving outcomes: case-matched comparison of novel second-generation versus first-generation self-expandable transcatheter heart valves. Eur J Cardiothorac Surg 2016; 50 (02) 368-373
• 18 Joseph L, Bashir M, Xiang Q. et al. Prevalence and outcomes of mitral stenosis in patients undergoing transcatheter aortic valve replacement: findings from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry. JACC Cardiovasc Interv 2018; 11 (07) 693-702
• 19 Grover FL, Vemulapalli S, Carroll JD. et al; STS/ACC TVT Registry. 2016 Annual Report of The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. J Am Coll Cardiol 2017; 69 (10) 1215-1230
• 20 Adler Y, Fink N, Spector D, Wiser I, Sagie A. Mitral annulus calcification--a window to diffuse atherosclerosis of the vascular system. Atherosclerosis 2001; 155 (01) 1-8
• 21 Biancari F, Rosato S, D'Errigo P. et al; OBSERVANT Research Group. Immediate and intermediate outcome after transapical versus transfemoral transcatheter aortic valve replacement. Am J Cardiol 2016; 117 (02) 245-251
• 22 Koifman E, Magalhaes M, Kiramijyan S. et al. Impact of transfemoral versus transapical access on mortality among patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Cardiovasc Revasc Med 2016; 17 (05) 318-321
• 23 Suh WM, Kern MJ. Addressing the hemodynamic dilemma of combined mitral and aortic stenosis. Catheter Cardiovasc Interv 2008; 71 (07) 944-949
• 24 Unger P, Rosenhek R, Dedobbeleer C, Berrebi A, Lancellotti P. Management of multiple valve disease. Heart 2011; 97 (04) 272-277
• 25 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 2019; S0167-5273 (18)36307-1
• 26 Yang B, DeBenedictus C, Watt T. et al. The impact of concomitant pulmonary hypertension on early and late outcomes following surgery for mitral stenosis. J Thorac Cardiovasc Surg 2016; 152 (02) 394-400.e1
• 27 Wilbring M, Alexiou K, Tugtekin SM. et al. Pushing the limits-further evolutions of transcatheter valve procedures in the mitral position, including valve-in-valve, valve-in-ring, and valve-in-native-ring. J Thorac Cardiovasc Surg 2014; 147 (01) 210-219
• 28 Guerrero M, Dvir D, Himbert D. et al. Transcatheter mitral valve replacement in native mitral valve disease with severe mitral annular calcification: results from the first multicenter global registry. JACC Cardiovasc Interv 2016; 9 (13) 1361-1371