Prevalence of multiple native valvular heart disease in TAVR patients: a multicenter study assessing the impact of staged transcatheter edge-to-edge repair
Authors: Al-Kassou B , Kapplinghaus J , Meckelburg C , Shamekhi J , Aksoy A , Sugiura A , Zietzer A , Duesing P , Vogelhuber J , Weber M , Bakhtiary F , Grube E , Nickenig G , Zimmer S 
Published: October 2024

Abstract

Background
Multiple valvular heart disease (VHD) is associated with poor prognosis in patients undergoing TAVR. Existing research focuses either on mitral or tricuspid regurgitation (MR, TR), without providing comparative analysis of their long-term effects. Moreover, whether staged transcatheter edge-to-edge repair (TEER) improves outcomes in these patients is unknown.

Purpose
This multicenter study aimed to evaluate the prevalence of multiple VHD within a recent TAVR cohort and to assess and compare the impact of concomitant severe MR and TR on outcomes at both one and five years post-TAVR. Additionally, we aimed to examine the potential impact of staged TEER for severe VHD in patients treated with TAVR.

Methods
The study cohort consisted of 2,823 patients undergoing TAVR at our Heart Center between 2015 and 2022. This representative cohort was used to investigate the prevalence of multiple VHD in a contemporary TAVR population and to assess and compare the impact of severe MR and TR on outcomes following TAVR. Additionally, this cohort, along with TAVR cohorts from other Heart Centers, was screened for additional valvular intervention. Patients who underwent staged transcatheter edge-to-edge repair for severe MR (n=147) or TR (n=59) were included.

Results
A concomitant persistent severe VHD was observed in 369 (13.1%) patients, with 208 (7.4%) having a severe MR, and 161 (5.7%) having a severe TR. The one-year mortality was significantly higher in patients with a severe VHD compared to the overall cohort (9.0 vs 5.2 per 100 PY, p&lt;0.01). Notably, the highest one-year mortality was observed in patients with severe TR (13.3 per 100 PY) followed by patients with severe MR (6.4 per 100 PY) and those with no or a mild VHD (3.9 per 100 PY, p&lt;0.01). This difference persisted over five years, with mortality rates of 27.8 per 100 PY in TR patients compared to 16.7 and 10.6 per 100 PY in MR patients and those with no or a mild VHD (p&lt;0.01), Figure 1A. The landmark analysis revealed lower one-year mortality in patients who underwent staged TEER compared to those with severe VHD (4.1 vs 12.1 per 100 PY, p&lt;0.001). This trend continued at the five-year follow-up, with a mortality rate of 11.6 per 100 PY in the staged TEER group versus 25.8 per 100 PY in the group with severe VHD (p&lt;0.001), Figure 1B. The multivariate analyses revealed that concomitant severe TR was independently associated with one-year mortality (HR: 1.75 [95% CI: 1.14 – 2.67], p&lt;0.01).

Conclusion
A concomitant clinically significant VHD was prevalent among patients with AS undergoing TAVR. The persistence of severe VHD was associated with increased one- and five-year mortality following TAVR. Specifically, severe TR was associated with higher mortality rates compared to severe MR. The potential benefit of an additional staged TEER for concomitant VHD should be carefully considered, as it shows promise in improving outcomes for patients with persistent severe VHD after TAVR.