Years of progress have made TAVR more effective when treating concomitant mitral stenosis
Transcatheter aortic valve replacement (TAVR) with a contemporary balloon-expandable valve is a safe and effective treatment option for high-risk patients with severe aortic stenosis (AS) and concomitant severe mitral stenosis (MS), according to new research published in Circulation: Cardiovascular Interventions.[1] This represents significant progress in the treatment of structural heart disease; TAVR was previously associated with certain risks when treating severe AS and severe MS at the same time, but improvements in valve technology have proven to be successful.
“Current balloon-expandable valves reflect improvements in skirt designs and sealing mechanisms, which have resulted in much-improved rates of paravalvular leak, an important predictor of short- and long-term mortality after TAVR,” wrote first author Anirudh Kumar, MD, an interventional cardiologist with Northwestern Medicine, and colleagues. “Additionally, changes in deployment depth and improved procedural planning using tomographic imaging have resulted in decreased rates of permanent pacemaker (PPM) implantation. Moreover, significant advancements in percutaneous mitral therapies may allow for complete treatment in select patients.”
Hoping to confirm whether or not these improvements have resulted in improved outcomes, Kumar et al. focused on data from more than 200,000 TAVR patients treated with a contemporary balloon-expandable TAVR valve from Edwards Lifesciences—the Sapien 3, Sapien 3 Ultra or Sapien 3 Ultra Resilia—from June 2015 to December 2022. All data came from the Society of Thoracic Surgeons/American College of Cardiology TVT Registry.
Overall, severe MS—defined as a mean gradient >10 mm Hg or an area <1.5 cm2—was seen in 3.6% of patients. Researchers performed propensity score matching to compare 8,495 pairs of patients. Each pair included a patient with severe MS with a patient with mild MS or less.
After 30 days, patients with severe MS were more likely to undergo an aortic valve reintervention (0.1% vs. 0%) or require a PPM (11.3% vs. 9.4%) than patients with mild or less MS. Other than those two differences, however, 30-day outcomes were comparable between the two groups. This means the short-term risks of mortality, stroke and major bleeding events were not significantly influenced by the presence of severe MS.
At one year, patients with severe MS were linked to a slightly higher rates of all-cause mortality (17.6%) than patients with mild or less MS (16%). All other outcomes, including changes in quality of life as determined by Kansas City Cardiomyopathy Questionnaire (KCCQ) answers, were still comparable after that first year.
After three years, meanwhile, all-cause mortality was significantly higher among patients with severe MS (45.1%) than those with mild or less MS (40.9%). Again, all other outcomes remained comparable.
“While early data exploring the use of TAVR in patients with concomitant severe MS suggested markedly worse short- and mid-term outcomes, improvements in valve design and changes in contemporary deployment practices have bridged this gap, resulting in substantial short-term improvements in outcomes,” the authors wrote. “While mid-term outcomes remain worse among patients with severe MS undergoing TAVR, it is important to acknowledge that they garner similar quality-of-life improvements post-TAVR as their counterparts without severe MS. In summary, our results support the contemporary use of TAVR with a balloon-expandable valve as a valid and effective option for treating high-risk patients with aortic stenosis in the presence of concomitant severe MS.”
Click here to read the full study in Circulation: Cardiovascular Interventions, an American Heart Association journal.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.