Incidence and management of multiple native valvular heart disease in patients undergoing TAVR: Impact of staged valvular interventions on outcomes
Authors: Al-Kassou B , Kapplinghaus J , Shamekhi J , Aksoy A , Tiyerili V , Weber M , Nickenig G , Zimmer S 
Published: November 2023

Abstract

Background
Multiple valvular heart disease (VHD) is a prevalent condition among patients undergoing TAVR. Previous studies have reported increased one-year mortality in TAVR patients with concomitant mitral (MR) and tricuspid regurgitation (TR). However, the long-term impact of multiple VHD on TAVR outcomes is not known. Moreover, most studies investigating additional VHD either focus on the evaluation of MR or TR, without a head-to-head comparison of VHD. Finally, it is not known whether an additional staged transcatheter valvular intervention for concomitant VHD may improve outcomes.

Purpose
Our Aim was to evaluate the incidence of multiple VHD in a real-world TAVR cohort, to assess and compare the impact of concomitant severe MR and TR on outcomes at one and five years after TAVR, and to examine the rate and impact of a staged edge-to-edge intervention for concomitant VHD.

Methods
The study cohort included 2058 patients with severe aortic stenosis undergoing TAVR between February 2014 and May 2022. All patients have been screened for additional staged valvular intervention. Clinical endpoints included one- and five-year mortality following TAVR.

Results
A concomitant severe VHD was observed in 168 (8.2%) patients undergoing TAVR, of whom 68 (3.3%) patients had a severe TR and 100 (4.9%) had a severe MR. A moderate TR was seen 240 (11.7%) patients, whereas a moderate MR was detectable in 477 (23.2%) patients. An additional staged edge-to-edge valvular intervention was performed in 20 (1.0%) and 37 (1.8%) patients due to a severe TR and MR, respectively. The overall one- and five-year all-cause mortality rates were 11.2% and 27.3% following TAVR. The one-year all-cause mortality was significantly higher in patients with a concomitant severe VHD (17.9%) as compared to patients with mild/no VHD (9.0%, p&lt;0.01). Of interest, the highest one-year mortality was observed in patients with a concomitant severe TR (20.6%), followed by patients with a severe MR (16.0%) and mild/no VHD (9.0%, p&lt;0.01), Figure 1. This difference was sustained for up to five years after TAVR (Figure 2 A, p&lt;0.01). An additional staged edge-to-edge valvular intervention was associated with decreased one-year mortality rate as compared to patients with a persistent severe VHD (5.2% vs 18.9%, p=0.02). This association was sustainable over the follow-up period of five years (Figure 2 B, p&lt;0.01). Multivariate regression analyses revealed that a concomitant severe TR (OR: 2.53 [95% CI: 1.42 – 4.50], p&lt;0.01) was independently associated with the mortality following TAVR.

Conclusion
Severe concomitant VHD was associated with an increased one- and five-year mortality following TAVR. In this context, a severe TR appears to be associated with a higher mortality rate as compared to a severe MR. A staged edge-to-edge valvular intervention for concomitant VHD may improve outcomes in these patients and should be critically evaluated in patients with persistent severe VHD after TAVR.Figure 1Figure 2