General characteristics of patients(Table 1)
Table 1
Comparison of baseline characteristics between the two groups
Patient characteristics | MR improved (n = 38) | MR nonimproved(n = 37) | p value |
Age, years | 72.26.±7.58 | 72.78 ± 8.01 | 0.773 |
Male, n(%) | 26/38 (68.4%) | 22/37 (59.5%) | 0.664 |
Height,(cm) | 165.39 ± 8.36 | 165.95 ± 8.79 | 0.782 |
Weight, (kg) | 60.24 ± 14.31 | 61.11 ± 13.72 | 0.789 |
Body mass index, (kg/m2) | 22.07 ± 4.74 | 21.81 ± 3.52 | 0.792 |
Smoke, n(%) | 5/38(13.2%) | 3/37(8.1%) | 0.738 |
Hyperlipidemia, n(%) | 11/38 (28.9%) | 11/37 (29.7%) | 0.941 |
Hypertension, n(%) | 30/38 (78.9%) | 21/37 (56.8%) | 0.039 |
Diabetes mellitus, n(%) | 2/38 (5.3%) | 5/37 (13.5%) | 0.213 |
Atrial fibrillation, n(%) | 10/38 (26.3%) | 8/37 (21.6%) | 0.634 |
COPD, n(%) | 3/38 (7.9%) | 4/37 (10.8%) | 0.664 |
Previous PCI, n(%) | 1/38 (2.6%) | 3/37 (8.1%) | 0.281 |
PPM, n(%) | 1/38 (2.6%) | 3/37 (8.1%) | 0.281 |
Peripheral vascular disease, n(%) | 0/38 (0%) | 1/37 (2.7%) | 0.232 |
Renal insufficiency, n(%) | 0/38(0%) | 4/37(10.8%) | 0.015 |
Symptom, n(%) | 22/38(57.9%) | 17/37(45.9%) | 0.300 |
Left bundle branch block, n(%) | 0/38(0%) | 3/37(8.1%) | 0.037 |
Right bundle branch block, n(%) | 4/38(10.5%) | 0/37(0%) | 0.017 |
Atrioventricular block, n(%) | 7/38(18.4%) | 5/37(13.5%) | 0.562 |
NYHA functional class III /IV, n(%) | 33/38 (86.8%) | 30/37(81.1%) | 0.496 |
Hemoglobin, (g/L) | 125.37 ± 19.96 | 124.30 ± 20.06 | 0.817 |
Serum creatinine, (mg/dl) | 107.34 ± 93.56 | 95.54 ± 36.23 | 0.148 |
NT-proBNP,(ng/pl) | 1397.38 ± 1407.72 | 1501.58 ± 1763.88 | 0.778 |
ALT,(U/L) | 26.11 ± 14.81 | 25.59 ± 19.74 | 0.476 |
STS risk score,(%) | 5.41 ± 1.82 | 5.45 ± 1.88 | 0.933 |
Abbreviations: ALT, alanine aminotransferase; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; PPM, permanent pacemake; NYHA, New York Heart Association; STS, Society of Thoracic Surgeons. |
Seventy-five patients were enrolled, including 37 suffering from persistent MR, with a mean age of 72.26 ± 7.58 years, 48 males and 27 females.
Comparison of baseline clinical information and imaging data of patients in the MR-improved and MR-nonimproved groups(Table 2)
Table 2
Comparison of baseline imaging information between the two groups
| MR improved(n = 38) | MR nonimproved(n = 37) | p value |
Echocardiography | | | |
LVEF, (%) | 49.24 ± 9.3 | 57.97 ± 10.85 | <0.001 |
LAED,(mm) | 44.21 ± 5.79 | 42.92 ± 5.69 | 0.333 |
LVEDd,(mm) | 57.00 ± 7.77 | 54.14 ± 6.82 | 0.094 |
LVEDs ,(mm) | 42.34 ± 8.52 | 37.76 ± 6.98 | 0.013 |
IVS ,(mm) | 11.14 ± 1.85 | 10.77 ± 1.37 | 0.347 |
LVOTD,(mm) | 30.31 ± 3.66 | 29.80 ± 3.18 | 0.572 |
Severe aortic regurgitation,n(%) | 37/37 (100%) | 35/35(100%) | - |
Aortic valve peak velocity,(m/s) | 2.05 ± 0.84 | 1.89 ± 0.65 | 0.355 |
Mean valve gradient,(mmHg) | 9.434 ± 0.39 | 8.75 ± 0.44 | 0.702 |
Effective orifice area ,(cm2)/ | 2.88 ± 0.67 | 2.77 ± 0.63 | 0.450 |
Severe AR, n(%) | 38/38(100%) | 37/37(100%) | - |
Moderate to severe FMR, n(%) | 11/38 (28.9%) | 1/37 (2.7%) | 0.002 |
Moderate to severe TR, n(%) | 6/38 (15.8%) | 3/37 (8.1%) | 0.302 |
PASP,(mmHg) | 37.79 ± 9.83 | 37.27 ± 9.48 | 0.817 |
Computed tomography | | | |
Aortic annulus area,(mm2) | 525.16 ± 74.47 | 512.66 ± 72.72 | 0.257 |
Aortic annulus perimeter,(mm) | 84.46 ± 7.10 | 82.37 ± 6.49 | 0.245 |
Aortic annulus long axis diameter,(mm) | 28.66 ± 2.58 | 27.84 ± 2.58 | 0.237 |
Largest diameter of ascending aorta ,(mm) | 35.41 ± 5.39 | 35.95 ± 5.18 | 0.698 |
Abbreviations: LVEF, left ventricular ejection fraction; LAED, left atrial end dimension; LVEDd, left ventricle end dimension diastole; LVEDs, left ventricle end dimension systole; LVPWd, left ventricular posterior wall thickness at end-diastole; LVOTD, left ventricular outflow tract diameter; IVS, interventricular septal thickness; MR, mitral regurgitation; TR, tricuspid regurgitation; PASP, pulmonary artery systolic pressure |
In terms of clinical information, compared with the MR nonimproved group, more patients in the MR improved group were diagnosed with renal dysfunction (10.8% vs. 0%, p = 0.015) and hypertension (78.9%vs. 56.8%, p = 0.039). More right bundle branch blocks (10.5% vs. 0%) and fewer left bundle branch blocks (0% vs. 8.1%) appeared in these patients. There were no significant differences in baseline age, male sex, height, weight, body mass index, smoking, hyperlipidemia, diabetes mellitus, atrial fibrillation, previous percutaneous coronary intervention, permanent pacemaker implantation, peripheral vascular disease, renal insufficiency, symptoms, atrioventricular block,New York Heart Association functional class III or IV, hemoglobin, serum creatinine, NT-proBNP, alanine aminotransferase, or Society of Thoracic Surgeons (STS) score between the two groups. The TTE examination showed that patients in the MR-improved group had a lower ejection fraction (49.24 ± 9.37 vs. 57.97 ± 10.85, p<0.001) and larger left ventricle end dimension systole ( LVEDs )(42.34 ± 8.52 vs. 37.76 ± 6.98, p = 0.013). A higher proportion of patients in the MR-improved group had moderate to severe MR (28.9% vs. 2.7%, p = 0.002). No significant differences were found between these two groups in left ventricle end dimension diastole, left ventricle end dimension diastole, LVEDs, interventricular septal thickness, left ventricular outflow tract diamete, severe aortic regurgitation, aortic valve peak velocity, mean valve gradient, effective orifice area, severe AR, moderate to severe tricuspid regurgitation, pulmonary artery systolic pressure, aortic annulus area, aortic annulus perimeter or aortic annulus long axis diameter.
Comparison of preoperative and postoperative echocardiographic follow-up in the MR-improved and MR-nonimproved groups
The overall decrease in MR degree after TAVR was observed only in the MR improvement group.(preoperative vs. postoperative 1 day vs. postoperative 1 month, p = 0.001) and postoperative AR severity was significantly improved in both groups (preoperative vs. postoperative 1 day vs. postoperative 1 month, p<0.001).(Figure 1. A-D). Figure 2 shows the AR and MR before TAVR and 1-month post TAVR.under echocardiography examination.
Analysis of in-hospital and postoperative 1-month endpoint events(Table 3)
Table 3
Comparison of clinical end-points at different follow-up time points between the two
Clinical end-points n(%) | In-hospital | 30-days |
MR improved(n = 38) | MR nonimproved(n = 37) | P1 | MR improved(n = 38) | MR nonimproved(n = 37) | P2 |
Primary endpoints | | | | | | |
All-cause mortality | 0(0.0%) | 0(0.0%) | - | 0(0.0%) | 0(0.0%) | - |
Cardiovascular mortality | 0(0.0%) | 0(0.0%) | - | 0(0.0%) | 0(0.0%) | - |
Secondary endpoints | | | | | | |
Bleeding event | 0(0.0%) | 1(2.7%) | 0.241 | 0(0.0%) | 1(2.7%) | 0.241 |
Major Vascular complication | 1(2.6%) | 0(0.0%) | 0.321 | 0(0.0%) | 0(0.0%) | - |
Acute renal failure | 0(0.0%) | 0(0.0%) | - | 0(0.0%) | 0(0.0%) | - |
Stroke | 0(0.0%) | 1(2.7%) | 0.241 | 0(0.0%) | 1(2.7%) | 0.241 |
Myocardial infarction | 0(0.0%) | 0(0.0%) | - | 0(0.0%) | 0(0.0%) | - |
New AF | 4(10.5%) | 3(8.1%) | 0.718 | 0(0.0%) | 0(0.0%) | - |
New LBBB | 5(13.5%) | 9(24.3%) | 0.235 | 0(0.0%) | 1(2.7%) | 0.241 |
New AVB | 7(18.9%) | 9(24.3%) | 0.572 | 1(2.6%) | 1(2.7%) | 0.985 |
New complete AVB | 2(5.3%) | 3(8.1%) | 0.620 | 1(2.6%) | 0(0.0%) | 0.321 |
New PPM | 7(18.9%) | 8(21.6%) | 0.772 | 1(2.6%) | 1(2.7%) | 0.985 |
Endocarditis | 0(0.0%) | 0(0.0%) | | 0(0.0%) | 0(0.0%) | - |
PVL | 3(7.9%) | 6(16.2%) | 0.264 | 4(10.5%) | 3(8.1%) | 0.718 |
Rehospitalization | 0 (0%) | 0 (0%) | - | 1 (2.6%) | 3 (8.1%) | 0.281 |
Abbreviations: AF, atrial fibrillation; LBBB, left bundle branch block; AVB, atrioventricular block; PPM, permanent pacemaker; PVL, perivalvular leakage. |
There was no significant difference in primary and secondary endpoints in patients with or without improvement of MR who underwent TAVR in the hospital and 1 month after the operation. All-cause death or cardiac death did not occur in the two groups. During hospitalization, bleeding events, major vascular complications, stroke, new-onset atrial fibrillation, new-onset left bundle branch block, new-onset atrioventricular block, new-onset complete atrioventricular block, permanent pacemaker implants and moderate-to-severe paravalvular leaks were 0%, 2.6%, 0%, 10.5%, 13.5%, 18.9%, 5.3%, 18.9% and 7.9% in the MR improved group and 2.7%, 0%, 2.7%, 8.1%, 24.3%, 24.3%, 8.1%, 21.6% and 16.2% in the MR nonimproved group, respectively. In the one-month follow-up, 2.6% new-onset atrioventricular block, 2.6% new-oneset complete atrioventricular block, 2.6% new permanent permanent pacemaker implantation, 10.5% moderate to severe PVL and 2.6% rehospitalization were observed in the MR-improved group. The nonimproved MR group had 2.7% bleeding events, 2.7% stroke, 2.7% new left bundle block, 2.7% new-oneset atrioventricular block, 2.7% permanent pacemaker, 8.1% moderate to severe paravalvular leaks and 8.1% rehospitalization.
Univariable and multivariable logistic regression analyses for FMR improvement in PSAR patients post-TAVR(Table 4)
Table 4
Variables | Univariate analysis | Multivariate analysis |
OR | 95%CI | P | OR | 95%CI | P |
MR degree | 2.806 | 1.446–5.443 | 0.002 | 2.180 | 1.068–4.449 | 0.032 |
LVEDs | 1.078 | 1.014–1.147 | 0.016 | - | - | - |
Hypertension | 2.857 | 1.035–7.888 | 0.043 | 4.033 | 1.177–13.819 | 0.026 |
LVEF | 0.920 | 0.875–0.967 | 0.001 | 0.938 | 0.887–0.993 | 0.026 |
Abbreviations: MR, mitral regurgitation; LVEDs, left ventricle end dimension systole; LVEF, left ventricular ejection fraction |
The results of univariable and multivariable logistic regression analyses for the significant TR are shown in Table 4. Among the variables, MR degree, LVEDs, hypertension, and LVEF were associated with FMR improvement. (all p < 0.05). In the multivariable analysis, MR degree, hypertension, and LVEF were independently associated with significant TR.