title: Impact of mitral regurgitation on clinical outcomes of patients with low-ejection fraction, low-gradient severe aortic stenosis undergoing transcatheter aortic valve implantation.
abstract: BACKGROUND
  Up to 1 in 6 patients undergoing transcatheter aortic valve implantation (TAVI) present with low-ejection fraction, low-gradient (LEF-LG) severe aortic stenosis and concomitant relevant mitral regurgitation (MR) is present in 30% to 55% of these patients. The effect of MR on clinical outcomes of LEF-LG patients undergoing TAVI is unknown.
  
  
  RESULTS
  Of 606 consecutive patients undergoing TAVI, 113 (18.7%) patients with LEF-LG severe aortic stenosis (mean gradient ≤40 mm Hg, aortic valve area <1.0 cm(2), left ventricular ejection fraction <50%) were analyzed. LEF-LG patients were dichotomized into ≤mild MR (n=52) and ≥moderate MR (n=61). Primary end point was all-cause mortality at 1 year. No differences in mortality were observed at 30 days (P=0.76). At 1 year, LEF-LG patients with ≥moderate MR had an adjusted 3-fold higher rate of all-cause mortality (11.5% versus 38.1%; adjusted hazard ratio, 3.27 [95% confidence interval, 1.31-8.15]; P=0.011), as compared with LEF-LG patients with ≤mild MR. Mortality was mainly driven by cardiac death (adjusted hazard ratio, 4.62; P=0.005). As compared with LEF-LG patients with ≥moderate MR assigned to medical therapy, LEF-LG patients with ≥moderate MR undergoing TAVI had significantly lower all-cause mortality (hazard ratio, 0.38; 95% confidence interval, 0.019-0.75) at 1 year.
  
  
  CONCLUSIONS
  Moderate or severe MR is a strong independent predictor of late mortality in LEF-LG patients undergoing TAVI. However, LEF-LG patients assigned to medical therapy have a dismal prognosis independent of MR severity suggesting that TAVI should not be withheld from symptomatic patients with LEF-LG severe aortic stenosis even in the presence of moderate or severe MR.
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Crochan J
authors: CJ
authors: O'Sullivan
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Stefan
authors: S
authors: Stortecky
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Anne
authors: A
authors: Bütikofer
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Dik
authors: D
authors: Heg
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Thomas
authors: T
authors: Zanchin
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Christoph
authors: C
authors: Huber
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Thomas
authors: T
authors: Pilgrim
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Fabien
authors: F
authors: Praz
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Lutz
authors: L
authors: Buellesfeld
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Ahmed A
authors: AA
authors: Khattab
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Stefan
authors: S
authors: Blöchlinger
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Thierry
authors: T
authors: Carrel
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Bernhard
authors: B
authors: Meier
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Stephan
authors: S
authors: Zbinden
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
authors: Peter
authors: P
authors: Wenaweser
authors: From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.). Stephan.Windecker@insel.ch.
authors: Stephan
authors: S
authors: Windecker
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008944:Mitral Valve Insufficiency / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D018579:Patient Selection; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013318:Stroke Volume; D013557:Switzerland; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: aortic valve stenosis; mitral valve insufficiency; transcatheter aortic valve implantation