Transcatheter Aortic Valve Implantation in Patients with Mitral Annular Calcification or Mitral Stenosis: Analysis of Acute Hemodynamic Changes and Acute and Long-Term Outcomes

Objectives: Mitral annular calcification (MAC) was described before as risk factor for impaired outcomes in transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. Reports of influence of concomitant mitral stenosis (MS) on outcomes in TAVI procedures are scarce.

Methods: Between November 2009 and June 2017, 1,058 patients (pts.) (54.8% female, 80.8 ± 6.8 years, log EuroSCORE I 19.1 ± 13.2) underwent TAVI in the presence of concomitant MAC or MS. Subgroups were built including 352/1,058 (33.3%) pts. with MAC, 528/1,058 (49.9%) pts. with mild MS, 167/1,058 (15.8%) pts. with moderate MS, and 11/1,058 (1.0%) pts. with severe MS. Multivariate logistic regression, COX regression, and Kaplan–Meier survival analysis were performed. Hemodynamic thresholds for impaired outcomes were analyzed by receiver operating characteristics (ROC) method.

Results: VARC-2 device success and early safety were 90.6% (933/1,058) and 81.2% (837/1,058). Overall 30-day mortality was 7.5% (79/1,058) with highest mortality in patients with moderate and severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 100%; p < 0.001). Multivariate logistic regression presented moderate/severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94–16.26, p < 0.001), impaired LVEF (OR: 1.38, CI: 1.10–1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11–1.67, p < 0.01) as predictive for 30-day survival. Kaplan–Meier analysis presented lowest long-term survival in patients with MAC and mild MS without influence of transfemoral or transapical approach. Left ventricular systolic/diastolic pressure drop of ˃59.5/˃19.5 mm Hg after TAVI was associated with increased mortality with a positive predictive value of 72.3/95.7% and a negative predictive value of 93.3/93.3%.

Conclusion: TAVI in the presence of MAC/MS is associated with acceptable acute outcomes in MAC and mild MS and should be considered high-risk procedures in patients with moderate and severe MSs with distinctly increased early mortality rates. Our results suggest adverse hemodynamics after TAVI with remaining MS, which may be contributed to underfilling of the left ventricle leading to acute low-cardiac output.

No conflict of interest has been declared by the author(s).