Di Bacco L.

Donatelli F.

Glauber M.

Miceli A.

English

Archivio istituzionale della ricerca - Università di Brescia

International Journal of Cardiology 322 (2021) 95–96Contents lists available at ScienceDirectInternational Journal of Cardiologyj ourna l homepage: www.e lsev ie r .com/ locate / i j ca rdEditorialCan we solve two problems with a TAVR?Antonio Miceli a,⁎,1, Lorenzo Di Bacco a,1, Francesco Donatelli b, Mattia Glauber aa Minimally invasive Cardiac Surgery Department, Istituto Clinico Sant'Ambrogio, Italyb Chair of Cardiac Surgery, Department of Clinical and Community Sciences, University of Milan, ItalySevere aortic stenosis (AS) is often associatedwith variable grades of predictors of persistency and worsening of MR. Predictors may bemitral regurgitation (MR). Several studies suggest that a significantgrade ofMR in AS patients undergoing isolated aortic valve replacement(AVR) is linked to worse outcomeswith higher rate of mortality and re-duced adverse event free survival [1–3]. Guidelines recommend AVRand concomitant mitral valve treatment in patients with AS and signif-icant symptomatic MR [4]. However, the optimal treatment for thesepatients is still debated, especially in presence of moderate MR.The removal of aortic obstruction reduces the left ventricle (LV)pressure overload, induces LV reverse remodeling and decreases mitralvalve leaflets tethering,with consequent improvement ofMR.However,benefits related to this mechanism seem to be associated only to func-tional MR [4–6].An increasing number of patients are scheduled for transcatheterAVR (TAVR) treatment. In these patients, significant MR ranges from 2to 30% of cases. After TAVR, MR is expected to improve because of thereverse remodeling and optimization of medical therapy. Nevertheless,data on TAVR and MR report contrasting results. Some studies havedemonstrated an increase risk of early and late mortality whereasothers have shown an improvement of MR after AS correction [1,3].In the issue of this Journal, Ben-Assa and colleagues sought to investi-gate the prevalence and the impact of postoperative MR after TAVR onoutcomes in an intermediate-low risk population [7]. In a propensity-matched study, authors compared the outcomes of patients with resid-ualmore thanmoderate and less thanmoderate postoperativeMR. Inter-estingly, 25% of patients had an improvement of MR, in 19% of cases MRgot worse and in 56% of patients MR did not change. Of note, 16.8% ofpatients had post-procedural moderate-to-severe post-operative MR.Post-operative significant MR was associated with increased mortalityand reduced event free survival at 4 years follow-up. Moreover,moderate-to-severe MR was associated with poor hemodynamic out-comes at 6-month follow-up. Finally, pre-operative MR > grade II wasa strong predictor of higher grade of post-operative MR.TAVR might not produce the expected improvements on MR, be-cause of LV dynamics and pressure fillings. In this setting, preoperativecardiac imaging and hemodynamic studies are helpful in identifying⁎ Corresponding author at: Minimally Invasive Cardiac Surgery Department, IstitutoClinico Sant'Ambrogio, Via LG Faravelli, Milano, Italy.E-mail address: antoniomiceli79@alice.it (A. Miceli).1 Antonio Miceli and Lorenzo Di Bacco contributed equally to the manuscript.https://doi.org/10.1016/j.ijcard.2020.08.1050167-5273/© 2020 Elsevier B.V. All rights reserved.assessed by trans-thoracic/trans-esophageal echocardiograph, CardiacMagnetic Resonance (MRI) and CT scan. Results of echocardiographyand MRI are often discordant, and some studies report MRI is superiorin detecting myocardial fibrosis and quantifying MR [8]. Nevertheless,using echocardiographic parameters, Ben-Assa and colleagues showedthat patients with larger atria, lower right ventricular function and car-diac index were more likely to have postoperative moderate-to-severeMR. Other risk factors for post-procedural MR worsening are annularcalcification, dilated mitral annuls and leaflet stiffness detected at thetransesophageal Echocardiography and/or CT-Scans [9].Authors suggest also that the type of prosthesis plays a role in MRworsening hypothesizing that self-expanding valves may interferewithmitral anterior leaflet. In this regard, Cortés and colleagues demon-strated that self-expandable valves are associated with increased mor-tality, suggesting its potential negative effect on post-operative MR[9]. Furthermore, Caballero and colleagues demonstrated that in pa-tients with tricuspid aortic valve Balloon-Expandable valve determineslow stress on mitro-aortic continuity with consequent improvementin left ventricle hemodynamics and MR [10]. Finally, other importantdeterminants for MR worsening are LV dyssynchrony after permanentpacemaker implantation and volume overload from significantparavalvular leakage.The wide diffusion of transcatheter aortic valve implantation proce-dure and its extension on intermediate and low risk patients raises thequestion how to deal with concomitant mitral valve regurgitation. Thedecision to treat or not to treat both valves is generally based on the se-verity and etiology of MR and patient'smorbidity. Because surgical dou-ble valve treatment may increase mortality and morbidities, theadoption of hybrid strategies, such as transcatheter approaches for MRtreatment, could be reasonable in high-risk patients, but to date, few ex-periences are reported. These techniques are not available in all centersand fewpatients are effectively eligible for transcathetermitral valve in-tervention [10].The use of TAVR for treatment of AS alone in patientswith associatedMR is reasonable in high-risk patients but requires a careful evaluationin patients with lower risk, where double valve treatment through aminimally invasive approach might be the best treatment option.Declaration of Competing InterestAuthors have not conflict of interest to declare related to this paper.A. Miceli, L. Di Bacco, F. Donatelli et al. International Journal of Cardiology 322 (2021) 95–96References[1] M. Barbanti, J.G. Webb, R.T. Hahn, T. Feldmann, R.H. Boone, C.R. Smith, S. Kodali,et al., Impact of preoperative moderate/severe mitral regurgitation on 2-year out-come after transcatheter and surgical aortic valve replacement. Insight from theplacement of aortic transcatheter valve (PARTNER) trial cohort A, Circulation 128(2013) 2776–2784.[2] A. D’Onofrio, V. Gasparetto, M. Napodano, R. Bianco, G. Tarantini, V. Renier, G.Isabella, et al., Impact of preoperative mitral valve regurgitation on outcomes aftertranscatheter aortic valve implantation, Eur. J. Cardiothorac. Surg. 41 (2012)1271–1277.[3] B.E. Stähli, M. Reinthaler, D.M. Leistner, U. Landmesser, A. Lauten, Transcatheter aor-tic valve replacement and concomitant mitral regurgitation, Front. Cardiovasc. Med.5 (2018) 74, https://doi.org/10.3389/fcvm.2018.00074.[4] H. Baumgartner, V. Falk, J.J. Bax, M. De Bonis, C. Hamm, P.J. Holm, B. Iung, et al., 2017ESC/EACTS guidelines for the management of valvular heart disease. The task forcefor the Management of Valvular Heart Disease of the European Society of Cardiology(ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), Eur. HeartJ. 38 (2017) 2739–2791.96[5] C.J. O’Sullivan, D. Tüller, R. Zbinden, F.R. Eberli, Impact of mitral regurgitation onclinical outcomes after transcatheter aortic valve implantation, Interv. Cardiol. Rev.11 (1) (2016) 54–58, https://doi.org/10.15420/icr.2016:11:1.[6] L. Harling, S. Saso, O.A. Jarral, A. Kourliourus, E. Kidher, T. Athanasiou, Aortic valvereplacement for aortic stenosis in patients with concomitant mitral regurgitation:should the mitral valve be dealt with? Eur. J. Cardiothorac. Surg. 40 (2011)1087–1096.[7] E. Ben-Assa, S. Biner, S. Banai, Y. Arbel, M. Laufer-Perl, J. Kramarz, et al., Clinical im-pact of post procedural mitral regurgitation after transcatheter aortic valve replace-ment, Int. J. Cardiol. 299 (2019) 215–227 in press.[8] S. Uretsky, L. Gillam, R. Lang, et al., Discordance between echocardiography and MRIin the assessment of mitral regurgitation severity: a prospective multicenter trial, J.Am. Coll. Cardiol. 65 (2015) 1078–1088.[9] C. Cortés, I.J. Amat-Santos, L. Nombela-Franco, et al., Mitral regurgitation after Trans-catheter aortic valve replacement: prognosis, imaging predictors, and potentialmanagement, JACC Cardiovasc. Interv. 9 (2016) 1603–1614.[10] A. Caballero, W. Mao, R. McKay, et al., The impact of balloon-expandable transcath-eter aortic valve replacement on concomitantmitral regurgitation: a comprehensivecomputational analysis, J. R. Soc. Interface 16 (2019) 20190355, https://doi.org/10.1098/rsif.2019.0355.

Can we solve two problems with a TAVR?

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Can we solve two problems with a TAVR?

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