Martina Patané (Ferrarotto Hospital, Catania, Italy) and colleagues found that percutaneous edge-to-edge repair (MitraClip, Abbott Vascular), either as a planned staged treatment or as a bailout therapy, is feasible and effective approach in mitral regurgitation patients who have undergone transcatheter aortic valve implantation (TAVI).1 In this interview, Patané talks to Cardiovascular News about the percutaneous options for managing patients with aortic stenosis and mitral regurgitation.
How many patients with aortic stenosis will also have mitral?
Aortic Stenosis is frequently associated with mitral regurgitation and at the time of aortic valve replacement, up to two thirds of patients have varying degrees of mitral regurgitation. The aetiology of concomitant mitral regurgitation can be degenerative or functional. Most of the available data demonstrate a trend towards an improvement of mitral regurgitation after isolated aortic valve replacement, particularly when mitral regurgitation has a functional aetiology. Also, more than half of patients do not require further interventions on the mitral valve after undergoing aortic valve replacement.
What data are available for the combined surgical management of aortic stenosis and mitral regurgitation?
There is a general consensus that severe mitral regurgitation associated with aortic stenosis should be corrected at the time of surgical aortic valve replacement, especially if it is degenerative. On the other hand, the management of moderate mitral regurgitation and severe functional mitral regurgitation remains controversial, considering that double valve surgery is associated with higher (up to two fold) periprocedural mortality and morbidity compared with isolated surgical aortic valve replacement and considering that mitral regurgitation may eventually improve after aortic valve replacement. However, mitral regurgitation may remain stable or even worsen. Also, subsequent reintervention for mitral valve repair or replacement is associated with an increased operative risk.
Prior to your study, what data were available for the combined percutaneous management of aortic stenosis and mitral regurgitation?
Current literature on combined percutaneous treatment of aortic stenosis and mitral regurgitation is scarce. Only two studies with limited number of patients and short follow-up are available. Rudolph et al assessed that bivalvular transcatheter treatment of patients with coexisting aortic stenosis and mitral regurgitation is technically feasible, even in a single session. In this series, mortality was high (36%) and double valve therapy was associated with only moderate mid-term efficacy in terms of symptomatic improvement. Conversely, Kische et al found a significant improvement in
What did your study find?
In our study we found a significant improvement in functional status. At median follow up of 552 days (range: 7–2,215), we had no cases of rehospitalisation for heart failure, one cardiovascular death at day seven, and two cases of non-cardiovascular death (at 916 and 1,757 days). Echocardiography showed no cases of transcatheter aortic valve failure and worsening in mitral regurgitation severity compared to discharge echo was only observed in two patients (16.6%) (from mild to moderate).
Based on the available CE marked devices, which percutaneous mitral regurgitation device is best suited to be used in combination with TAVI?
Transcatheter aortic valves do not interfere with a subsequent percutaneous intervention on the mitral valve. Even if Abbott Vascular’s percutaneous edge-to-edge repair system (MitraClip) is the most well-known device used for percutaneous intervention in such cases, the use of transcatheter direct annuloplasty systems (Valtech’s Cardioband and Mitralign’s MPAS) can be also considered. The choice of the mitral device should be tailored on the anatomical features of the mitral valve of each patient.
What further studies are needed in this area?
A study including a larger population with longer follow-up and that randomize mitral percutaneous intervention and medical therapy after TAVI, is essential in this important and interesting area.
- Patané et al. EuroPCR 2016 abstract presentation.