Mitral Regurgitation in Low-Flow, Low-Gradient Aortic Stenosis Patients Undergoing TAVR: Insights From the TOPAS-TAVI Registry

Afonso B. Freitas-Ferraz, Stamatios Lerakis, Henrique Barbosa Ribeiro, Martine Gilard, João L. Cavalcante, Raj Makkar, Howard C. Herrmann, Stephan Windecker, Maurice Enriquez-Sarano, Asim N. Cheema, Luis Nombela-Franco, Ignacio Amat-Santos, Antonio J. Muñoz-García, Bruno Garcia del Blanco, Alan Zajarias, John C. Lisko, Salim Hayek, Vasilis Babaliaros, Florent Le Ven, Thomas G. GleasonTarun Chakravarty, Wilson Y. Szeto, Marie Annick Clavel, Alberto de Agustin, Vicenç Serra, John T. Schindler, Abdellaziz Dahou, Mohamed Salah Annabi, Emilie Pelletier-Beaumont, Philippe Pibarot, Josep Rodés-Cabau

Research output: Contribution to journalArticlepeer-review

14 Scopus citations


Objectives: This study sought to determine the incidence, clinical impact, and changes over time of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR). Background: Few data exist on the clinical impact and changes in severity over time of MR in patients with LFLG-AS undergoing TAVR. Methods: A total of 308 TAVR candidates with LFLG-AS were included. Patients were categorized according to MR severity at baseline, and presence of MR improvement at 12-month follow-up. Clinical outcomes were assessed at 1 and 12 months (+ echocardiography), and yearly thereafter. Results: Baseline mild and moderate-to-severe MR were present in 118 (38.3%) and 115 (37.3%) patients, respectively. MR was of functional and mixed etiology in 77.2% and 22.7% of patients, respectively. A total of 131 patients (42.5%) died after a median follow-up of 2 (1 to 3) years. Baseline moderate-or-greater MR had no impact on mortality (hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 0.72 to 2.48) or heart failure hospitalization (HR: 1.02; 95% CI: 0.49 to 2.10). At 1-year follow-up, MR improved in 44.3% of patients and remained unchanged/worsened in 55.7%. The lack of MR improvement was associated with a higher risk of all-cause and cardiac mortality (HR: 2.02; 95% CI: 1.29 to 3.17; HR: 3.03; 95% CI: 1.27 to 7.23, respectively), rehospitalization for cardiac causes (HR: 1.50; 95% CI: 1.04 to 2.15), and an increased overall-mortality/heart failure rehospitalization (HR: 1.94; 95% CI: 1.25 to 3.02). A higher baseline left ventricular end-diastolic diameter and a higher increase in left ventricular ejection fraction were found to be independent predictors of MR improvement at 1-year follow-up (odds ratio: 0.69; 95% CI: 0.51 to 0.94; and odds ratio: 0.81; 95% CI: 0.67 to 0.96, respectively). Conclusions: Most TAVR candidates with LFLG-AS had some degree of MR, of functional origin in most cases. MR improved in about one-half of patients, with larger left ventricular size and a higher increase in left ventricular ejection fraction post-TAVR determining MR improvement over time. The lack of MR improvement at 1 year was associated with poorer outcomes.

Original languageEnglish (US)
Pages (from-to)567-579
Number of pages13
JournalJACC: Cardiovascular Interventions
Issue number5
StatePublished - Mar 9 2020
Externally publishedYes


  • low-flow low-gradient aortic stenosis
  • mitral regurgitation
  • reduced left ventricular ejection fraction
  • transcatheter aortic valve replacement

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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