Moderate or Severe Functional MR and Severe AS: Is Mitral Valve Surgery Justified?

Abstract

Objective Mitral regurgitation (MR) and severe aortic valve stenosis often coexist. Concomitant replacement of both valves is associated with a significantly higher morbidity and mortality. This study sought to investigate the progression of MR after isolated aortic valve replacement.

Methods We analyzed the severity and progression of MR, survival and echocardiographic parameters in 506 patients with severe aortic valve stenosis and moderate to severe functional MR who received isolated aortic valve replacement during a 9-year period.

Results Transcatheter aortic valve implantation (TAVI) was performed in 381 patients and 125 patients received surgical aortic valve replacement (SAVR). The median age of the cohort was 82 years. Median ejection fraction before and after TAVI or SAVR was 35 and 36% respectively (p = 0.64). There was a statistically significant reduction in the MR (p < 0.001) within both groups. Survival in both groups at 5 years was at 25%.

Conclusion Isolated aortic valve replacement in patients with accompanying moderate to severe functional MR may present an adequate treatment option for this high-risk patient collective.

Keywords

aortic valve - mitral valve surgery - ischemic - heart disease - angina - echocardiography

Authors' Contribution

Clarence Pingpoh, MD: Substantial contributions to the conception and design of the work, acquisition, analysis and interpretation of data for the work. Drafting the work and revising it critically for important intellectual content, and final approval of the version to be published.

Duchelle Donfack: Substantial contributions to the acquisition, analysis and interpretation of data for the work, revising the work critically for important intellectual content, and final approval of the version to be published.

Tim Berger, MD: Substantial contributions to the conception of the work and revising it critically for important intellectual content. Final approval of the version to be published.

Maximillian Kreibich, MD: Substantial contributions to the conception of the work and revising it critically for important intellectual content, and final approval of the version to be published.

Friedhelm Beyersdorf, MD: Substantial contributions to the conception of the work and revising it critically for important intellectual content. Final approval of the version to be published.

Paul Puiu, MD: Substantial contributions to the acquisition, analysis and interpretation of data for the work. Revising it critically for important intellectual content and final approval of the version to be published.

Holger Schroefel, MD: Substantial contributions to the conception of the work and revising it critically for important intellectual content, and final approval of the version to be published.

Willibald Hochholzer, MD: Substantial contributions to the conception of the work and revising it critically for important intellectual content. Final approval of the version to be published.

Martin Czerny, MD: Substantial contributions to the conception of the work and revising it critically for important intellectual content. Final approval of the version to be published.

Matthias Siepe, MD: Substantial contributions to the conception and design of the work, acquisition, analysis and interpretation of data for the work, drafting the work and revising it critically for important intellectual content, and final approval of the version to be published.

All authors agree 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.

Publication History

Received: 03 May 2021

Accepted: 15 June 2021

Article published online:
22 November 2021

• References

• 1 Moazami N, Diodato MD, Moon MR. et al. Does functional mitral regurgitation improve with isolated aortic valve replacement?. J Card Surg 2004; 19 (05) 444-448
• 2 Sannino A, Losi MA, Schiattarella GG. et al. Meta-analysis of mortality outcomes and mitral regurgitation evolution in 4,839 patients having transcatheter aortic valve implantation for severe aortic stenosis. Am J Cardiol 2014; 114 (06) 875-882
• 3 Galloway AC, Grossi EA, Baumann FG. et al. Multiple valve operation for advanced valvular heart disease: results and risk factors in 513 patients. J Am Coll Cardiol 1992; 19 (04) 725-732
• 4 Belhaj Soulami R, Anselmi A, Leurent G, Verhoye J-P. Simultaneous transapical aortic and mitral valve implantation in a patient with porcelain aorta. Eur J Cardiothorac Surg 2019; 56 (06) 1202-1203
• 5 Lehmann S, Merk DR, Etz CD. et al. Porcine xenograft for aortic, mitral and double valve replacement: long-term results of 2544 consecutive patients. Eur J Cardiothorac Surg 2016; 49 (04) 1150-1156
• 6 Mueller XM, Tevaearai HT, Stumpe F. et al. Long-term results of mitral-aortic valve operations. J Thorac Cardiovasc Surg 1998; 115 (06) 1298-1309
• 7 Falk V, Baumgartner H, Bax JJ. et al; ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. [published correction appears in Eur J Cardiothorac Surg 2017 Oct 1;52(4):832] Eur J Cardiothorac Surg 2017; 52 (04) 616-664
• 8 Brener SJ, Duffy CI, Thomas JD, Stewart WJ. Progression of aortic stenosis in 394 patients: relation to changes in myocardial and mitral valve dysfunction. J Am Coll Cardiol 1995; 25 (02) 305-310
• 9 Schulman DS, Remetz MS, Elefteriades J, Frances CK. Mild mitral insufficiency is a marker of impaired left ventricular performance in aortic stenosis. J Am Coll Cardiol 1989; 13 (04) 796-803
• 10 Nishimura RA, Otto CM, Bonow RO. et al. AHA/ACC guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol 2014; 2014: e57-e185
• 11 Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet 2009; 373 (9672): 1382-1394
• 12 Hutter A, Bleiziffer S, Richter V. et al. Transcatheter aortic valve implantation in patients with concomitant mitral and tricuspid regurgitation. Ann Thorac Surg 2013; 95 (01) 77-84
• 13 Otsuji Y, Handschumacher MD, Schwammenthal E. et al. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 1997; 96 (06) 1999-2008
• 14 Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112 (05) 745-758
• 15 Zoghbi WA, Adams D, Bonow RO. et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2017; 30 (04) 303-371
• 16 Vahanian A, Alfieri O, Andreotti F. et al; Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33 (19) 2451-2496
• 17 Grayburn PA, Carabello B, Hung J. et al. Defining “severe” secondary mitral regurgitation: emphasizing an integrated approach. J Am Coll Cardiol 2014; 64 (25) 2792-2801
• 18 Christenson JT, Jordan B, Bloch A, Schmuziger M. Should a regurgitant mitral valve be replaced simulataneously with a stenotic aortic valve?. Tex Heart Inst J 2000; 27 (04) 350-355
• 19 Nombela-Franco L, Eltchaninoff H, Zahn R. et al. Clinical impact and evolution of mitral regurgitation following transcatheter aortic valve replacement: a meta-analysis. Heart 2016; 102 (09) 728
• 20 De Bonis M, Lapenna E, La Canna G. et al. Mitral valve repair for functional mitral regurgitation in end-stage dilated cardiomyopathy: role of the “edge-to-edge” technique. Circulation 2005; 112 (9, Suppl): I402-I408
• 21 De Bonis M, Lapenna E, Barili F. et al. Long-term results of mitral repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: does the technique matter?. Eur J Cardiothorac Surg 2016; 50 (05) 882-889