Background: Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly high- and moderate- or even low-risk patients suffering from severe symptomatic degenerative aortic stenosis (AS). The coexistence of both, mitral and tricuspid regurgitation (MR, TR) and their dynamics after TAVI is likely to be of prognostic relevance and should be carefully evaluated before and during follow-up. Thereby, special emphasis should be placed on the question, whether and when patients might benefit from, mainly interventional, treatment of MR or TR after TAVI. The current study was aimed to elucidate the prognostic value of MR and TR before and after TAVI in a prospective real-world single-center registry study.

Methods: A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included. A wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed in the frame of the local study protocol at baseline as well as 6 weeks and 6 months after TAVI. Mortality was recorded at 30 days, 12 months and 2 years after TAVI.

Results: The mean age of patients in this typical TAVI cohort was 78.7 ± 7.3 years, 52% were female and the mean STS score was 5 ± 3.9%. All patients were successfully treated by TAVI using the transfemoral access route using whether balloon- or self-expanding prostheses. The mortality rates were as follows: 3.6% after 30 days, 16.4% after 1 and 22.6% after 2 years. With respect to disease entity, there were 74% high-, 16% low- and 10% paradoxical low-flow low-gradient AS. Moderate or severe (relevant) MR occurred in 39% and relevant TR in 32% of the patients at baseline. After 6 weeks, these rates were 27% for relevant MR (p=0.001) and 35% for relevant TR (p=n.s.). For relevant MR, the rate after 6 months was 24% (p=0.036, compared to baseline) and 34% for relevant TR (p=n.s., compared to baseline). The rate of relevant paravalvular leakage (PVL, moderate or severe aortic regurgitation) after TAVI was 10% after 6 weeks and 9% after 6 months. Multivariate analysis could identify the following independent predictors of 2-year mortality: female sex, age, AS entity other than high-gradient, atrial fibrillation, renal function, relevant TR, systolic pulmonary artery pressure (PAPsys) and six-minute walk test (SMWT) at baseline; clinical frailty scale and PAPsys at 6 weeks and BNP as well as relevant MR at 6 months after TAVI. Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant TR at baseline (31.6% versus 17.4%, p<0.001) as well as those with relevant MR at 6 months (12.1% versus 4.8%, p=0.042). Despite not being identified as independent mortality predictor, survival rates were significantly lower in patients showing relevant PVL at 6 months (20% versus 6.1%, p=0.013).

Conclusions: Taken together, the results of the current real-life experience clearly demonstrate the prognostic importance of accurate and repeated evaluation of mitral and tricuspid regurgitation in TAVI patients both, at baseline and during follow-up. Thus, there is an urgent clinical need to perform large randomized trials to investigate the potential role of interventional MR treatment, e.g., by transcatheter edge-to-edge repair, at the right time-point after TAVI, which hitherto remains ambiguous.