Moderate-to-Severe AR After TAVR May Yield Greater Mortality Risk

Patients with moderate-to-severe aortic regurgitation (AR) after transcatheter aortic valve replacement (TAVR) are more likely to die during follow-up compared with patients who have less severe AR, according to findings released at TCT 2014.

Researchers led by Marina Urena, MD, of the Quebec Lung and Heart Institute and Laval University in Canada, looked at how the degree and acuteness of AR at presentation affected outcomes over a follow-up period of 21±17 months among 1,735 patients who underwent TAVR. Residual AR was mild in 43.9% and moderate-to-severe in 14.2%.

Moderate-to-severe AR was associated with a greater mortality risk compared with trace or no AR (adjusted HR=1.88; 95% CI, 1.37-2.58; P<.001) and mild AR (adjusted HR=1.69; 95% CI, 1.27-2.25; P<.001). About two-thirds of patients with moderate-to-severe AR had acute AR; that subgroup had a higher risk of death compared with patients with trace, no or mild AR (adjusted HR=2.37; 95% CI, 1.53-3.66; P<.001) and chronic moderate-to-severe AR (adjusted HR=2.24; 95% CI, 1.17-4.30; P=.015).

Patients with mild AR were not at increased risk for mortality compared with those with trace or no AR (P=.393). Also, those with chronic moderate-to-severe AR had mortality rates similar to those with trace, no or mild AR (P>.50).

“This study confirms that the occurrence of mild AR after TAVR has no impact on 2-year clinical outcomes, suggesting that additional therapeutic measures other than systematic follow-up are not necessary in such patients,” Urena told TCT Daily.

“[These findings are] of high clinical relevance considering both the high incidence of mild residual AR and the potentially deleterious effects and costs associated with additional measures for the treatment of paravalvular leaks,” she said. Such measures include balloon post-dilation, implantation of a second valve, percutaneous closure of the paravalvular leak with vascular plugs and cardiac surgery with removal of the transcatheter valve. 

Because the elevated mortality risk was associated mostly with acute—rather than chronic—moderate-to-severe AR, Urena noted, it is those patients “in whom additional measures should be promptly implemented to decrease the regurgitant volume.”

She added that changes in LVEF were similar between the two groups over time and that patients in the acute AR subgroup experienced more mitral regurgitation over time than did others.

“In patients with moderate-to-severe residual AR but no increase in AR severity compared with baseline, closer follow-up is probably a reasonable option, as it has been in most patients diagnosed with chronic AR,” Urena said. “Additional [remedies for] paravalvular leaks in such patients should be implemented during the follow-up period if any significant deterioration in clinical status and/or ventricular function parameters occurs.”

Disclosures:

• Urena reports no relevant conflicts of interest.