Combining TAVR and TMVR: 

Simultaneous Interventional Aortic And Mitral Valve Replacement

In Degenerated Bioprostheses Or Mitral AnnularCalcification

Nina Feirer1,2, Nora Zahlmann1,2, KetiVitanova1,2,3, Markus Krane1,2,3,4, Hendrik Ruge1,2,3

1 German Heart Center Munich, Department of Cardiovascular Surgery, Technical University Munich, Germany; 2 Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University Munich, Germany; 3 DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany; 4 Yale School of Medicine, Division of Cardiac Surgery, Department of Surgery, New Haven, USA.

Objectives

With aging patient population, the demand for patient-tailored treatment of failing biological or transcatheter prostheses is rising. While transcatheter valve-in-valve implantation is established for high-risk patients, TMVR is also gaining importance. The outcome of patients with simultaneous TAVR/TMVR is not yet well analyzed.

Methods

Preoperative screening of patients for double valve intervention included 4D-CT analyzing mitral annular and neo-LVOT morphology, and aortic root anatomy. Procedural characteristics, perioperative complications, and bioprosthetic valve function were assessed according to VARC-3 criteria. Follow-up included TTE and evaluation of NYHA class.

Results

Baseline characteristics  

Age  72.7 ± 11.8 years

Female gender   8 (61.5%) 

Median logEuroScore    24.6% ± 15.5%

NYHA Class  III to IV

Periprocedural characteristics

Stroke  0 (0%)

Conversion to surgery    0 (0%)

Reexploration for bleeding  1 (7.7%)

Permanent pacemaker     2 (15.4%) 

Hospital length of stay  6.7 days (min. 3 - max. 11 days)

Anticoagulation at discharge  Aspirin with Factor Xa inhibitor or Phenprocoumon

NYHA Class at discharge  I to II

30-day mortality  2 (15.4%)

TTE at discharge

No/mild MR  12 (92.3%)

MR I-II  1 (7.7%)

Mean MV gradient   5 ± 1mmHg

Mean AV gradient   12.8 ± 8.1mmHg

Follow-Up   

Median Follow-Up time  2.4 ± 2.9 years

NYHA Class  I to II 

Kaplan-Meier estimated survival   69.2% at 1 year, 51.9% at 2 years

Conclusion

Careful CT-based patient selection can identify eligible patients for simultaneous TAVR/TMVR. In high-risk patients with aortic valve stenosis and mitral valve disease with MAC or failing bioprosthesis,  early mortality after combined TAVR/TMVR was lower than predicted by risk scores. Simultaneous TAVR/TMVR provides a fast recovery and solid relief of symptoms.