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Canadian Journal of Cardiology

Clinical Impact of Preprocedural Moderate or Severe Mitral Regurgitation on Outcomes After Transcatheter Aortic Valve Replacement

Published:December 31, 2019DOI:https://doi.org/10.1016/j.cjca.2019.12.022

      Abstract

      Background

      The influence of improved mitral regurgitation (MR) on the outcomes of transcatheter aortic valve replacement (TAVR) is unknown. Our aim was to determine the impact of significant preprocedural MR and the improvement of MR after TAVR.

      Methods

      A population of 1587 patients from the Optimized Catheter Valvular Intervention Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry were evaluated. Preprocedural MR was mild or less in 1443 patients (90.9%) and moderate or severe in 144 patients (9.1%).

      Results

      Moderate or severe MR was associated with increased risk for all-cause mortality at 1 year (adjusted hazard ratio, 1.85; 95% confidence interval [CI], 1.20-2.84; P = 0.005) and 2 years (adjusted hazard ratio, 1.64; 95% CI, 1.15-2.34; P = 0.007). At 6 months after TAVR, the MR grade improved in 77.4% of the patients with moderate or severe baseline MR. Multivariate analysis showed that the absence of previous myocardial infarction (odds ratio, 8.00; 95% CI, 1.74-36.8; P = 0.008) and beta-blocker use at baseline (odds ratio, 2.71; 95% CI, 1.09-6.70; P = 0.031) were independently associated with improved MR at 6 months (vs unchanged, worsened MR, or death). Patients with improved MR had a significantly lower rate of midterm readmission for heart failure (11.6%) than those with unchanged or worsened MR (30.8%, P = 0.007).

      Conclusions

      Moderate or severe MR was associated with increased risk of all-cause mortality 2 years after TAVR. Moderate or severe baseline MR was improved in most patients at 6 months after TAVR. Patients with unchanged or worsened MR had an increased rate of readmission for heart failure.

      Résumé

      Contexte

      L’effet d’une amélioration de la régurgitation mitrale (RM) sur l’issue du remplacement valvulaire aortique par cathéter (RVAC) est inconnu. Notre objectif était de déterminer la portée d’une forte RM préopératoire et l’amélioration de la RM après le RVAC.

      Méthodologie

      Une population de 1 587 patients inscrits au registre OCEAN-TAVI (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation) a été évaluée. La RM préopératoire était tout au plus légère chez 1 443 patients (90,9 %) et modérée ou sévère chez 144 patients (9,1 %).

      Résultats

      La RM modérée ou sévère était associée à une augmentation du risque de décès toutes causes confondues à 1 an (rapport des risques instantanés corrigé : 1,85; intervalle de confiance [IC] à 95 % : 1,20-2,84; p = 0,005) et à 2 ans (rapport des risques instantanés corrigé : 1,64; IC à 95 % : 1,15-2,34; p = 0,007). Six mois après le RVAC, la classification de la RM indiquait une amélioration de celle-ci chez 77,4 % des patients qui présentaient initialement une atteinte modérée ou sévère. Une analyse multivariée a montré que l’absence d’antécédents d’infarctus du myocarde (rapport de cotes : 8,00; IC à 95 % : 1,74-36,8; p = 0,008) et l’usage de bêtabloquants au départ (rapport de cotes : 2,71; IC à 95 % : 1,09-6,70; p = 0,031) étaient indépendamment associés à l’amélioration de la RM à 6 mois (vs la persistance de la RM sans changement, l’aggravation de la RM ou le décès). Chez les patients présentant une amélioration de la RM, le taux de réhospitalisation à moyen terme pour cause d’insuffisance cardiaque était significativement moindre (11,6 %) comparativement aux patients chez qui il y avait persistance de la RM sans changement ou aggravation de la RM (30,8 %, p = 0,007).

      Conclusions

      La RM modérée ou sévère était associée à un risque plus élevé de décès toutes causes confondues deux ans après le RVAC. Une amélioration de la RM initialement modérée ou sévère est survenue chez la plupart des patients six mois après le RVAC. Un taux plus élevé de réhospitalisation pour cause d’insuffisance cardiaque a été noté dans les cas de persistance de la RM sans changement ou d’aggravation de la RM.
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