Presentación de la ponencia "Insuficiencia mitral mas que moderada concomitante" por el Dr Nombela Franco en los Diálogos EPIC_Retos Clínicos en Válvulas Transcatéter/ Clinical Challenges in TAVR today, el 10 de Mayo de 2018 en Barcelona (España)

1. Luis Nombela Franco
Hospital Clínico San Carlos
Insuficiencia mitral más que
moderada concomitante

2. Datos demográficos
• Edad: 81 years
• Sexo: Female
• BMI: 29 ; BSA: 1,73
Antecedentes
• Hipertensión
• Diabetes con insulina (Hb glicada 7.6%)
• Enfermedad vascular periférica con
isquemia crónica MMII
• Función renal normal (eGFR:85ml/min)
Tratamiento:
• Insulina, metformina, AAS, Atorvastatina,
Candersartan, torasemida.
Caso Clínico 1
Situación basal:
• Vive sola (viuda) buen apoyo familiar por sus 2 hijos.
Asistencia domiciliaria (1vez/semana). Movilidad
limitada por claudicación intermitente en MMII

3. Datos demográficos
• Edad: 81 years
• Sexo: Female
• BMI: 29 ; BSA: 1,73
Antecedentes
• Hipertensión
• Diabetes con insulina (Hb glicada 7.6%)
• Enfermedad vascular periférica con
isquemia crónica MMII
• Función renal normal (eGFR:85ml/min)
Presentación clínica
• Ingreso por dolor torácico de esfuerzo y ocasionalmente de
reposo desde hace 2-3 semanas
Tratamiento:
• Insulina, metformina, AAS, Atorvastatina,
Candersartan, torasemida.
Caso Clínico 1
Situación basal:
• Vive sola (viuda) buen apoyo familiar por sus 2 hijos.
Asistencia domiciliaria (1vez/semana). Movilidad
limitada por claudicación intermitente en MMII

4. Datos demográficos
• Edad: 81 years
• Sexo: Female
• BMI: 29 ; BSA: 1,73
Antecedentes
• Hipertensión
• Diabetes con insulina (Hb glicada 7.6%)
• Enfermedad vascular periférica con
isquemia crónica MMII
• Función renal normal (eGFR:85ml/min)
Presentación clínica
• Ingreso por dolor torácico de esfuerzo y ocasionalmente de
reposo desde hace 2-3 semanas
Ecocardiograma TT:
• FEVI: 56%
• Estenosis aórtica severa (grad max/med
83/46mmHg, area: 0.77cm2)
• Insuficiencia mitral severa con calcificación
severa del anillo.
• IT leve-moderada, sin dilatación de anillo y
PSAP 51mmhg.
Tratamiento:
• Insulina, metformina, AAS, Atorvastatina,
Candersartan, torasemida.
Caso Clínico 1
Situación basal:
• Vive sola (viuda) buen apoyo familiar por sus 2 hijos.
Asistencia domiciliaria (1vez/semana). Movilidad
limitada por claudicación intermitente en MMII

5. Caso Clínico 1

6. Caso Clínico 1

7. Caso Clínico 1

8. Caso Clínico 1

9. Caso Clínico 1

10. Caso Clínico 1

11. Caso Clínico 1
Ecocardiograma TE:
• Válvula mitral con calcificación significativa del anillo, con prolapso de velo posterior
(P2) por rotura de cuerda tendinosa fibrocalcificada, que condiciona una IM severa
excéntrica (efecto coanda, VC 6mm, ERO 0.9cm2, e inversión de flujo en VVPP).
• Estenosis aórtica severa con Iao grado II

12. Caso Clínico 1
Ecocardiograma TE:
• Válvula mitral con calcificación significativa del anillo, con prolapso de velo posterior
(P2) por rotura de cuerda tendinosa fibrocalcificada, que condiciona una IM severa
excéntrica (efecto coanda, VC 6mm, ERO 0.9cm2, e inversión de flujo en VVPP).
• Estenosis aórtica severa con Iao grado II

13. Caso Clínico 1
Ecocardiograma TE:
• Válvula mitral con calcificación significativa del anillo, con prolapso de velo posterior
(P2) por rotura de cuerda tendinosa fibrocalcificada, que condiciona una IM severa
excéntrica (efecto coanda, VC 6mm, ERO 0.9cm2, e inversión de flujo en VVPP).
• Estenosis aórtica severa con Iao grado II

14. Caso Clínico 1
Ecocardiograma TE:
• Válvula mitral con calcificación significativa del anillo, con prolapso de velo posterior
(P2) por rotura de cuerda tendinosa fibrocalcificada, que condiciona una IM severa
excéntrica (efecto coanda, VC 6mm, ERO 0.9cm2, e inversión de flujo en VVPP).
• Estenosis aórtica severa con Iao grado II

15. Caso Clínico 1
HEART TEAM

16. 81 años, mujer, con diabetes, enfermedad vascular
periférica y coronaria de 3 vasos, Estenosis aórtica severa,
IM severa, hipertensión pulmonar moderada.
Caso Clínico 1
HEART TEAM

17. 81 años, mujer, con diabetes, enfermedad vascular
periférica y coronaria de 3 vasos, Estenosis aórtica severa,
IM severa, hipertensión pulmonar moderada.
STS: 9.91% Log Euroscore: 23.85%
Caso Clínico 1
Euroscore II: 16.86%
HEART TEAM

18. 81 años, mujer, con diabetes, enfermedad vascular
periférica y coronaria de 3 vasos, Estenosis aórtica severa,
IM severa, hipertensión pulmonar moderada.
STS: 9.91% Log Euroscore: 23.85%
Caso Clínico 1
Euroscore II: 16.86%
HEART TEAM
EVALUADA POR CIRUGÍA QUE RECHAZA POR
CALCIFICACIÓN SEVERA DEL ANILLO MITRAL

19. Caso Clínico 1

20. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%
* case-matched study; ** grade 4 or severe excluded
* Adapted from Nombela-Franco et al, JACC 2014
Impact of significant MR on Mortality after SAVR

21. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014

22. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None

23. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None 0
1
2
3
4

24. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None 0
1
2
3
4

25. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None
Trace
0
1
2
3
4

26. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None
Trace
Mild
Moderate
0
1
2
3
4
0
1
2
3
4

27. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None
Trace
Mild
Moderate
Mod-Sev
0
1
2
3
4
0
1
2
3
4

28. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None
Trace
Mild
Moderate
Mod-Sev
0
1
2
3
4
0
1
2
3
4

29. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR
* Adapted from Nombela-Franco et al, JACC 2014
None
Trace
Mild
Moderate
Mod-Sev
Severe
0
1
2
3
4
0
1
2
3
4

30. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded * Adapted from Nombela-Franco et al, JACC 2014
Impact of significant MR on Mortality after SAVR

31. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded * Adapted from Nombela-Franco et al, JACC 2014
Impact of significant MR on Mortality after SAVR

32. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded * Adapted from Nombela-Franco et al, JACC 2014
Impact of significant MR on Mortality after SAVR

33. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 0.10 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR

34. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 0.10 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR

35. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 0.10 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR

36. First Author,
Year (Ref.)
N
Etiology Grade of MR Early
mortality
p Time
Follow-up
(years)
Cumulative
survival
p Multivariat
e
Analysis
Absil, 2003* 58
FMR 100% 0-1 3.5%
0.67
8 years 60.9%
0.10 NA
116 58
2-3** 7.0% 55.0%
Moazani, 2004 72
FMR 100% 1-2 (trivial-mild) 5 years 89.1% 0.04
107 35
3-4 (mod-sev) 71.4%
Barreiro, 2005 338
FMR 21.4% no/mild 3.8% 0.2
1
10 years 40.1% 0.04 1.43
(1.03-1.98)
408 70
moderate** 7.1% 14.6%
Ruel, 2006 630
FMR 100% 0-1 NA 10 years
2.7 (1.5-4.7) 0.10 1.8 (0.9-3.4)
706 76 ≥2 NA
Caballero, 2008 419 FMR 100% No MR 5.6%
0.02
NA NA
572 153 Non-severe MR 10.5% NA
Wan, 2009* 91 FMR 100% 0-1 NA 10 years 43.4%
0.33 NA
182 91 ≥2 NA 48.3%
Takeda, 2010 134 FMR 41% No/trivial (0-1) 2.9%
0.60
10 years 90.3%
0.49 NA 193 59 Mild/mod
(2-3)**
1.7% 88.0%
Partner A, 2012 240
NA None/mild 7.1%
0.09
2 years 28.1%
0.04
1.77
(1.17-2.68) 299 59
Mod/sev 13.6% 49.8%* case-matched study; ** grade 4 or severe excluded
Impact of significant MR on Mortality after SAVR

37. 0
30
60
89
119
Adams
and Otto1
OverallBrasch
et al.5
Christenson
et al.4
Moazami
et al.7
1990 USA
n=21
1-Adam and Otto, Am J Cardiol 1990
2-Tunick et al, Am J Cardiol 1990
3-Harris et al, Am J Cardiol 1997
4-Christenson et al, Texas Heart Inst J 2000
5-Brasch et al, Am J Cardiol 2000
6-Absil et al, Eur J Cardiothoracic Surg 2003
7-Moazami et al, J Card Surg 2004
8-Barreiro et al, Circulation 2005
9-Ruel et al. Circulation 2006
10-Eynden et al Annals Thorac Surg 2007
Barreiro
et al.8
Tunick
et al2
% patients
Harris
et al.3
Absil
et al.6
71
29
91
9
87
13
100
0
56
44
26
74
30
65
18
82
37
63
56
44
38
61
Ruel
et al.9
Eynden
et al.10
1990 USA
n=11
1997 USA
n=15
2000
Switzerland
n=21
2000 USA
n=21
2003 Canada
n=58
2004 USA
n=20
2005 USA
n=11
2006 Canada
n=76
2007 Canada
n=16
n=268
Improved
No change
Changes in Functional Mitral Regurgitation after SAVR

38. 0
30
60
89
119
Adams
and Otto1
OverallBrasch
et al.5
Christenson
et al.4
Moazami
et al.7
1990 USA
n=21
1-Adam and Otto, Am J Cardiol 1990
2-Tunick et al, Am J Cardiol 1990
3-Harris et al, Am J Cardiol 1997
4-Christenson et al, Texas Heart Inst J 2000
5-Brasch et al, Am J Cardiol 2000
6-Absil et al, Eur J Cardiothoracic Surg 2003
7-Moazami et al, J Card Surg 2004
8-Barreiro et al, Circulation 2005
9-Ruel et al. Circulation 2006
10-Eynden et al Annals Thorac Surg 2007
Barreiro
et al.8
Tunick
et al2
% patients
Harris
et al.3
Absil
et al.6
71
29
91
9
87
13
100
0
56
44
26
74
30
65
18
82
37
63
56
44
38
61
Ruel
et al.9
Eynden
et al.10
1990 USA
n=11
1997 USA
n=15
2000
Switzerland
n=21
2000 USA
n=21
2003 Canada
n=58
2004 USA
n=20
2005 USA
n=11
2006 Canada
n=76
2007 Canada
n=16
n=268
Improved
No change
Changes in Functional Mitral Regurgitation after SAVR

39. 0
26
52
78
104
69.6
30.4
Worsened
Unchanged
Improved
Functional FunctionalOrganic Organic
0
Discharge Late follow-up
54.2
40.0
5.7
73.3
20.0
6.7
38.1
52.4
9.5
Takeda et al., Eur J Cardio-thoracic Surg 37 (2010)
% patients
Changes in Mitral Regurgitation according to the etiology after SAVR

40. 0
26
52
78
104
69.6
30.4
Worsened
Unchanged
Improved
Functional FunctionalOrganic Organic
0
Discharge Late follow-up
54.2
40.0
5.7
73.3
20.0
6.7
38.1
52.4
9.5
Takeda et al., Eur J Cardio-thoracic Surg 37 (2010)
% patients
Changes in Mitral Regurgitation according to the etiology after SAVR

41. Severe
Mod-sev
Nombela-Franco, et al JACC 2014
Incidence of Moderate-Severe MR in TAVR patients

42. Severe
Mod-sev
Nombela-Franco, et al JACC 2014
Incidence of Moderate-Severe MR in TAVR patients

43. Severe
Mod-sev
Nombela-Franco, et al JACC 2014
Incidence of Moderate-Severe MR in TAVR patients

44. Incidence of Moderate-Severe MR in TAVR patients
Mavromatis et al, Ann Thorac Surg 2017
TVT registry
(n=11,104)

45. Incidence of Moderate-Severe MR in TAVR patients
Mavromatis et al, Ann Thorac Surg 2017
TVT registry
(n=11,104)
0
10
20
30
40
CHOICE SAPIEN PARTNER-2 XT PARTNER-2 S3
9
16,8
32,7
36,9
RANDOMIZED TRIALS

46. 0
25
50
75
100
Samin4
n=16
1-Tzikas et al., CCI 2010
2-Samin et al., Int J Cardiol 2011
3-Durst et al. J Heart Valve Dis 2011
4-Samin et al., Int J Cardiol 2011
Hekimian5
n=90
Toggweiler6
n= 132
Giordana7
n=35
74
26
38
62
57
43
17
83
% patients
Overall
n=419
37
62
Tzikas1
n=54
50 50
81
19 18
82
Chiara2
n=58
Durst3
n=34
Functional
Organic
Mitral Regurgitation Etiology
5-Hekimian et al., J Am Soc Echocardiogr 2012
6-Toggweiler et al., JACC 2012
7-Giordana et al., Echocardiography 2013

47. 0
25
50
75
100
Samin4
n=16
1-Tzikas et al., CCI 2010
2-Samin et al., Int J Cardiol 2011
3-Durst et al. J Heart Valve Dis 2011
4-Samin et al., Int J Cardiol 2011
Hekimian5
n=90
Toggweiler6
n= 132
Giordana7
n=35
74
26
38
62
57
43
17
83
% patients
Overall
n=419
37
62
Tzikas1
n=54
50 50
81
19 18
82
Chiara2
n=58
Durst3
n=34
Functional
Organic
Mitral Regurgitation Etiology
5-Hekimian et al., J Am Soc Echocardiogr 2012
6-Toggweiler et al., JACC 2012
7-Giordana et al., Echocardiography 2013

48. Impact of MR on Early Mortality following TAVR
N Grade of MR Univariate Multivariate
Rodes-Cabau, 2010 339 Sev: 27 (8.0%) 2.40 (1.04-5.56) 3.01 (1.09-8.24)
Toggweiler, 2012 451 ≥Mod: 132 (29.3%) 2.04 (1.11-3.74) 2.10 (1.12-3.94)
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 9.3% vs 3%, p=0.10 -
Hutter, 2013 268 ≥Mod: 60 (22.4%) 13.3% vs 9.6%, p=ns -
Di Mario, 2013 4571 ≥2: 951 (20.8%) - 1.45 (1.08-1.93)
Sabaté, 2013 890 ≥3: 951 (6.2%) 3.28 (1.87-5.76) 4.12 (1.99-8.5)
Bedgoni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
11% vs 9% vs 5%
p=0.006
2.2 (1.78-3.28)
1.9 (1.1-3.3)
Barbanti, 2013 499 ≥Mod: 103 (20.6%) 3.9% vs 6.1%, p=0.41 -
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 3.8% vs 6.6%, p=0.52
* Only patients with low flow-low gradient

49. Impact of MR on Early Mortality following TAVR
N Grade of MR Univariate Multivariate
Rodes-Cabau, 2010 339 Sev: 27 (8.0%) 2.40 (1.04-5.56) 3.01 (1.09-8.24)
Toggweiler, 2012 451 ≥Mod: 132 (29.3%) 2.04 (1.11-3.74) 2.10 (1.12-3.94)
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 9.3% vs 3%, p=0.10 -
Hutter, 2013 268 ≥Mod: 60 (22.4%) 13.3% vs 9.6%, p=ns -
Di Mario, 2013 4571 ≥2: 951 (20.8%) - 1.45 (1.08-1.93)
Sabaté, 2013 890 ≥3: 951 (6.2%) 3.28 (1.87-5.76) 4.12 (1.99-8.5)
Bedgoni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
11% vs 9% vs 5%
p=0.006
2.2 (1.78-3.28)
1.9 (1.1-3.3)
Barbanti, 2013 499 ≥Mod: 103 (20.6%) 3.9% vs 6.1%, p=0.41 -
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 3.8% vs 6.6%, p=0.52
* Only patients with low flow-low gradient

50. Impact of MR on Early Mortality following TAVR
N Grade of MR Univariate Multivariate
Rodes-Cabau, 2010 339 Sev: 27 (8.0%) 2.40 (1.04-5.56) 3.01 (1.09-8.24)
Toggweiler, 2012 451 ≥Mod: 132 (29.3%) 2.04 (1.11-3.74) 2.10 (1.12-3.94)
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 9.3% vs 3%, p=0.10 -
Hutter, 2013 268 ≥Mod: 60 (22.4%) 13.3% vs 9.6%, p=ns -
Di Mario, 2013 4571 ≥2: 951 (20.8%) - 1.45 (1.08-1.93)
Sabaté, 2013 890 ≥3: 951 (6.2%) 3.28 (1.87-5.76) 4.12 (1.99-8.5)
Bedgoni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
11% vs 9% vs 5%
p=0.006
2.2 (1.78-3.28)
1.9 (1.1-3.3)
Barbanti, 2013 499 ≥Mod: 103 (20.6%) 3.9% vs 6.1%, p=0.41 -
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 3.8% vs 6.6%, p=0.52
* Only patients with low flow-low gradient

51. Impact of MR on Late Mortality following TAVR
N Grade of MR Univariate Multivariate Median FU
Leon, 2010 171 ≥Mod: 38 (22.2%) 23.7% vs. 32.3%, p=0.307 - 730
Smith, 2011 334 ≥Mod: 66 (19.8%) 24.2% vs. 24.6%, p=0.948 - 730
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 22% vs. 25%, p=0.21 -
Van Belle, 2012 3195 0: 1183 (37.0%)
1: 1351 (42.3%)
2: 661 (20.7%)
24% vs.
20.1% vs.
15.8%, p=0.002
1.16 (0.94–1.42),
1.09 (0.85–1.40),
p=0.39
Zahn, 2013 1391 ≥2: 42 (3.2%) 5.7% vs. 2.5%, p=0.009 1.57 (1.22–2.02) 392
Hutter, 2013 268 ≥Mod: 60 (22.4%) 30.2% vs 21.2%, p=0.068 -
Sabaté, 2013 890 ≥3: 55 (6.2%) 2.63 (1.58–4.36),p=0.001 1.67 (0.94–2.96) 244
Bedogni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
25% vs. 20% vs. 15%,
p=0.02
2.9 (2.5–3.8)
Khawaja, 2014 316 ≥3: 60 (19.0%) 28.3% vs. 20.2% p=0.023 4.94 (2.07-11.76) 365
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 38.1% vs. 11.5%, p=0.003 3.27 (1.31-8.15) 365
Cortes, 2016 1110 ≥3: 177(15.9%) 35.0% vs. 10.2%, p=0.001 - 182* Only patients with low flow-low gradient

52. Impact of MR on Late Mortality following TAVR
N Grade of MR Univariate Multivariate Median FU
Leon, 2010 171 ≥Mod: 38 (22.2%) 23.7% vs. 32.3%, p=0.307 - 730
Smith, 2011 334 ≥Mod: 66 (19.8%) 24.2% vs. 24.6%, p=0.948 - 730
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 22% vs. 25%, p=0.21 -
Van Belle, 2012 3195 0: 1183 (37.0%)
1: 1351 (42.3%)
2: 661 (20.7%)
24% vs.
20.1% vs.
15.8%, p=0.002
1.16 (0.94–1.42),
1.09 (0.85–1.40),
p=0.39
Zahn, 2013 1391 ≥2: 42 (3.2%) 5.7% vs. 2.5%, p=0.009 1.57 (1.22–2.02) 392
Hutter, 2013 268 ≥Mod: 60 (22.4%) 30.2% vs 21.2%, p=0.068 -
Sabaté, 2013 890 ≥3: 55 (6.2%) 2.63 (1.58–4.36),p=0.001 1.67 (0.94–2.96) 244
Bedogni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
25% vs. 20% vs. 15%,
p=0.02
2.9 (2.5–3.8)
Khawaja, 2014 316 ≥3: 60 (19.0%) 28.3% vs. 20.2% p=0.023 4.94 (2.07-11.76) 365
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 38.1% vs. 11.5%, p=0.003 3.27 (1.31-8.15) 365
Cortes, 2016 1110 ≥3: 177(15.9%) 35.0% vs. 10.2%, p=0.001 - 182* Only patients with low flow-low gradient

53. Impact of MR on Late Mortality following TAVR
N Grade of MR Univariate Multivariate Median FU
Leon, 2010 171 ≥Mod: 38 (22.2%) 23.7% vs. 32.3%, p=0.307 - 730
Smith, 2011 334 ≥Mod: 66 (19.8%) 24.2% vs. 24.6%, p=0.948 - 730
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 22% vs. 25%, p=0.21 -
Van Belle, 2012 3195 0: 1183 (37.0%)
1: 1351 (42.3%)
2: 661 (20.7%)
24% vs.
20.1% vs.
15.8%, p=0.002
1.16 (0.94–1.42),
1.09 (0.85–1.40),
p=0.39
Zahn, 2013 1391 ≥2: 42 (3.2%) 5.7% vs. 2.5%, p=0.009 1.57 (1.22–2.02) 392
Hutter, 2013 268 ≥Mod: 60 (22.4%) 30.2% vs 21.2%, p=0.068 -
Sabaté, 2013 890 ≥3: 55 (6.2%) 2.63 (1.58–4.36),p=0.001 1.67 (0.94–2.96) 244
Bedogni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
25% vs. 20% vs. 15%,
p=0.02
2.9 (2.5–3.8)
Khawaja, 2014 316 ≥3: 60 (19.0%) 28.3% vs. 20.2% p=0.023 4.94 (2.07-11.76) 365
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 38.1% vs. 11.5%, p=0.003 3.27 (1.31-8.15) 365
Cortes, 2016 1110 ≥3: 177(15.9%) 35.0% vs. 10.2%, p=0.001 - 182* Only patients with low flow-low gradient

54. Impact of MR on Late Mortality following TAVR
N Grade of MR Univariate Multivariate Median FU
Leon, 2010 171 ≥Mod: 38 (22.2%) 23.7% vs. 32.3%, p=0.307 - 730
Smith, 2011 334 ≥Mod: 66 (19.8%) 24.2% vs. 24.6%, p=0.948 - 730
D´Onofrio, 2012 176 ≥2: 43 (24.4%) 22% vs. 25%, p=0.21 -
Van Belle, 2012 3195 0: 1183 (37.0%)
1: 1351 (42.3%)
2: 661 (20.7%)
24% vs.
20.1% vs.
15.8%, p=0.002
1.16 (0.94–1.42),
1.09 (0.85–1.40),
p=0.39
Zahn, 2013 1391 ≥2: 42 (3.2%) 5.7% vs. 2.5%, p=0.009 1.57 (1.22–2.02) 392
Hutter, 2013 268 ≥Mod: 60 (22.4%) 30.2% vs 21.2%, p=0.068 -
Sabaté, 2013 890 ≥3: 55 (6.2%) 2.63 (1.58–4.36),p=0.001 1.67 (0.94–2.96) 244
Bedogni, 2013 1007 Mod: 243 (24.1%)
Sev: 94 (9.3%)
25% vs. 20% vs. 15%,
p=0.02
2.9 (2.5–3.8)
Khawaja, 2014 316 ≥3: 60 (19.0%) 28.3% vs. 20.2% p=0.023 4.94 (2.07-11.76) 365
O´Sullivan, 2015* 113 ≥Mod: 61 (54.0%) 38.1% vs. 11.5%, p=0.003 3.27 (1.31-8.15) 365
Cortes, 2016 1110 ≥3: 177(15.9%) 35.0% vs. 10.2%, p=0.001 - 182* Only patients with low flow-low gradient

55. 1 Sanino, AMJ 2014
2 Chakravarty AMJ 2015
3 Nombela-Franco, Heart 2015
4 Takagi, Ann Thorac Surg 2015
Impact of MR
on 1-year
mortality
following TAVR

56. 1 Sanino, AMJ 2014
2 Chakravarty AMJ 2015
3 Nombela-Franco, Heart 2015
4 Takagi, Ann Thorac Surg 2015
Impact of MR
on 1-year
mortality
following TAVR

57. Impact of MR on 1-year Mortality according to valve type
1 Sanino, AMJ 2014
2 Chakravarty AMJ 2015
3 Nombela-Franco, Heart 2015

58. Impact of MR on 1-year Mortality according to valve type
1 Sanino, AMJ 2014
2 Chakravarty AMJ 2015
3 Nombela-Franco, Heart 2015

59. Impact of MR on 1-year Mortality according to valve type
1 Sanino, AMJ 2014
2 Chakravarty AMJ 2015
3 Nombela-Franco, Heart 2015

60. PARTNER Cohort A, NEJM 2011
TAVR
Better
SAVR
Better
PARTNER Cohort B, NEJM 2011
TAVR
Better
Medical Tx
Better

61. PARTNER Cohort A, NEJM 2011
TAVR
Better
SAVR
Better
PARTNER Cohort B, NEJM 2011
TAVR
Better
Medical Tx
Better

62. 0
25
50
75
100
Global Moderate MR Severe MRImproved Unchanged Worsened
%
22.5
70.0
7.5
48.2
48.7
3.1
57.0
43.0
N=1288 N=386 N=135
11.1% to
no MR
37.1% to mild
MR
1.5% to no MR
31.1% to
mild MR
24.4% to
moderate MR
Nombela-Franco, et al Heart 2015
Changes in MR severity
following TAVR

63. Changes in MR severity according to valve type
Nombela-Franco, et al Heart 2015

64. Changes in MR severity according to valve type
Quantile regression analysis:
Improvement was 1 degree (1.0, 95% CI:
0.92-1.08, P=0.01) higher with BEV
Nombela-Franco, et al Heart 2015

65. PARTNER TRIAL
Changes in Mitral Regurgitation
Barbanti et al. ACC 2013

66. PARTNER TRIAL
Changes in Mitral Regurgitation
Barbanti et al. ACC 2013

67. Changes in MR
severity following
TAVR
Mavromatis et al, Ann Thorac Surg
TVT registry
(n=11,104)

68. Post-TAVR MR≥2 was an
independent predictor for
new onset AF, heart failure
and mortality
Biner S et al. ESC 2014
Does improvement matter?

69. Post-TAVR MR≥2 was an
independent predictor for
new onset AF, heart failure
and mortality
Biner S et al. ESC 2014
Does improvement matter?

70. Mavromatis et al, Ann Thorac Surg
Does improvement matter?

71. First Author,
Year
Factors Improvement Unchanged/
Worsened
P
Tzikas, 2010 Low LVEF 40±13 57±15 0.017
Durst, 2011 Absence of mitral annular calcification with restriction† 17% 61% 0.05
De Chiara, 2011 Deeper Implantation CV (mm)* 9.4±2.2 7.6±2.9 0.02
Samin, 2011 MR etiology (functional vs. organic) Δ -1.00±1.00‡
Δ -0.29±0.24‡
0.10
Hekimian, 2012 LVEF
LV end-systolic diameter
LV end-diastolic diameter
<50%
≥36mm
≥50mm
≥50%
<36mm
<50mm
0.009
0.002
0.001
Toggweiler, 2012 Absence of atrial fibrillation
Absence of pulmonary hypertension||
Mean gradient ≥40mmHg
MR etiology (functional vs. organic)
2.55 (1.17-5.55)
2.68 (1.09-6.58)
2.71 (1.19-6.18)
2.61 (1.15-5.93)
0.02
0.03
0.02
0.02
Giordana, 2013 Valve type (BEV vs. SEV)
Δ -1.4, p<0.001‡ Δ -0.6, p<0.21‡ -
Bedogni, 2013 Absence of atrial fibrillation
Absence of pulmonary hypertension#
MR etiology (functional vs. organic)
2.0 (1.9-2.9)
2.9 (2.7-3.3)
2.6 (1.8-3.1)
0.003
0.002
0.005
Cortes, 2016 Mitral annulus diameter (<35mm)
Mitral annulus calcification by CT
9 (3.2-25.3)
11.2 (4.0-31.3)
0.001
0.001
Kindya, 2018 MR etiology (functional vs. degenerative) 50% vs 35%, p=0.01
Predictors of Mitral Regurgitation Improvement

72. First Author,
Year
Factors Improvement Unchanged/
Worsened
P
Tzikas, 2010 Low LVEF 40±13 57±15 0.017
Durst, 2011 Absence of mitral annular calcification with restriction† 17% 61% 0.05
De Chiara, 2011 Deeper Implantation CV (mm)* 9.4±2.2 7.6±2.9 0.02
Samin, 2011 MR etiology (functional vs. organic) Δ -1.00±1.00‡
Δ -0.29±0.24‡
0.10
Hekimian, 2012 LVEF
LV end-systolic diameter
LV end-diastolic diameter
<50%
≥36mm
≥50mm
≥50%
<36mm
<50mm
0.009
0.002
0.001
Toggweiler, 2012 Absence of atrial fibrillation
Absence of pulmonary hypertension||
Mean gradient ≥40mmHg
MR etiology (functional vs. organic)
2.55 (1.17-5.55)
2.68 (1.09-6.58)
2.71 (1.19-6.18)
2.61 (1.15-5.93)
0.02
0.03
0.02
0.02
Giordana, 2013 Valve type (BEV vs. SEV)
Δ -1.4, p<0.001‡ Δ -0.6, p<0.21‡ -
Bedogni, 2013 Absence of atrial fibrillation
Absence of pulmonary hypertension#
MR etiology (functional vs. organic)
2.0 (1.9-2.9)
2.9 (2.7-3.3)
2.6 (1.8-3.1)
0.003
0.002
0.005
Cortes, 2016 Mitral annulus diameter (<35mm)
Mitral annulus calcification by CT
9 (3.2-25.3)
11.2 (4.0-31.3)
0.001
0.001
Kindya, 2018 MR etiology (functional vs. degenerative) 50% vs 35%, p=0.01
Predictors of Mitral Regurgitation Improvement

73. First Author,
Year
Factors Improvement Unchanged/
Worsened
P
Tzikas, 2010 Low LVEF 40±13 57±15 0.017
Durst, 2011 Absence of mitral annular calcification with restriction† 17% 61% 0.05
De Chiara, 2011 Deeper Implantation CV (mm)* 9.4±2.2 7.6±2.9 0.02
Samin, 2011 MR etiology (functional vs. organic) Δ -1.00±1.00‡
Δ -0.29±0.24‡
0.10
Hekimian, 2012 LVEF
LV end-systolic diameter
LV end-diastolic diameter
<50%
≥36mm
≥50mm
≥50%
<36mm
<50mm
0.009
0.002
0.001
Toggweiler, 2012 Absence of atrial fibrillation
Absence of pulmonary hypertension||
Mean gradient ≥40mmHg
MR etiology (functional vs. organic)
2.55 (1.17-5.55)
2.68 (1.09-6.58)
2.71 (1.19-6.18)
2.61 (1.15-5.93)
0.02
0.03
0.02
0.02
Giordana, 2013 Valve type (BEV vs. SEV)
Δ -1.4, p<0.001‡ Δ -0.6, p<0.21‡ -
Bedogni, 2013 Absence of atrial fibrillation
Absence of pulmonary hypertension#
MR etiology (functional vs. organic)
2.0 (1.9-2.9)
2.9 (2.7-3.3)
2.6 (1.8-3.1)
0.003
0.002
0.005
Cortes, 2016 Mitral annulus diameter (<35mm)
Mitral annulus calcification by CT
9 (3.2-25.3)
11.2 (4.0-31.3)
0.001
0.001
Kindya, 2018 MR etiology (functional vs. degenerative) 50% vs 35%, p=0.01
Predictors of Mitral Regurgitation Improvement

74. First Author,
Year
Factors Improvement Unchanged/
Worsened
P
Tzikas, 2010 Low LVEF 40±13 57±15 0.017
Durst, 2011 Absence of mitral annular calcification with restriction† 17% 61% 0.05
De Chiara, 2011 Deeper Implantation CV (mm)* 9.4±2.2 7.6±2.9 0.02
Samin, 2011 MR etiology (functional vs. organic) Δ -1.00±1.00‡
Δ -0.29±0.24‡
0.10
Hekimian, 2012 LVEF
LV end-systolic diameter
LV end-diastolic diameter
<50%
≥36mm
≥50mm
≥50%
<36mm
<50mm
0.009
0.002
0.001
Toggweiler, 2012 Absence of atrial fibrillation
Absence of pulmonary hypertension||
Mean gradient ≥40mmHg
MR etiology (functional vs. organic)
2.55 (1.17-5.55)
2.68 (1.09-6.58)
2.71 (1.19-6.18)
2.61 (1.15-5.93)
0.02
0.03
0.02
0.02
Giordana, 2013 Valve type (BEV vs. SEV)
Δ -1.4, p<0.001‡ Δ -0.6, p<0.21‡ -
Bedogni, 2013 Absence of atrial fibrillation
Absence of pulmonary hypertension#
MR etiology (functional vs. organic)
2.0 (1.9-2.9)
2.9 (2.7-3.3)
2.6 (1.8-3.1)
0.003
0.002
0.005
Cortes, 2016 Mitral annulus diameter (<35mm)
Mitral annulus calcification by CT
9 (3.2-25.3)
11.2 (4.0-31.3)
0.001
0.001
Kindya, 2018 MR etiology (functional vs. degenerative) 50% vs 35%, p=0.01
Predictors of Mitral Regurgitation Improvement

75. First Author,
Year
Factors Improvement Unchanged/
Worsened
P
Tzikas, 2010 Low LVEF 40±13 57±15 0.017
Durst, 2011 Absence of mitral annular calcification with restriction† 17% 61% 0.05
De Chiara, 2011 Deeper Implantation CV (mm)* 9.4±2.2 7.6±2.9 0.02
Samin, 2011 MR etiology (functional vs. organic) Δ -1.00±1.00‡
Δ -0.29±0.24‡
0.10
Hekimian, 2012 LVEF
LV end-systolic diameter
LV end-diastolic diameter
<50%
≥36mm
≥50mm
≥50%
<36mm
<50mm
0.009
0.002
0.001
Toggweiler, 2012 Absence of atrial fibrillation
Absence of pulmonary hypertension||
Mean gradient ≥40mmHg
MR etiology (functional vs. organic)
2.55 (1.17-5.55)
2.68 (1.09-6.58)
2.71 (1.19-6.18)
2.61 (1.15-5.93)
0.02
0.03
0.02
0.02
Giordana, 2013 Valve type (BEV vs. SEV)
Δ -1.4, p<0.001‡ Δ -0.6, p<0.21‡ -
Bedogni, 2013 Absence of atrial fibrillation
Absence of pulmonary hypertension#
MR etiology (functional vs. organic)
2.0 (1.9-2.9)
2.9 (2.7-3.3)
2.6 (1.8-3.1)
0.003
0.002
0.005
Cortes, 2016 Mitral annulus diameter (<35mm)
Mitral annulus calcification by CT
9 (3.2-25.3)
11.2 (4.0-31.3)
0.001
0.001
Kindya, 2018 MR etiology (functional vs. degenerative) 50% vs 35%, p=0.01
Predictors of Mitral Regurgitation Improvement

76. Symtomatic Severe Aortic Stenosis
SURGICAL
RISK Low/Intermediate High Prohibitive
MR
SEVERITY
None/Mild Moderate* Severe None/Mild Moderate* Severe None/Mild Moderate* Severe
SAVR
vs
TAVR
Double
Valve
intervention ‡
MR
MECHANISM
Functional Organic
LIKELIHOOD
IMPROVEMENT†
High Low
TREATMENT TAVR Medical therapy
vs.
TAVR
Potential evaluation of
Mitraclip or TVMR
Functional Organic Functional Organic
High Low
TAVR
vs.
Medical therapy
TAVR
vs
SAVR
TAVR Surgical Double
Valve
Intervention ‡
or
TAVR
Functional Organic
Potential evaluation of
Mitraclip or TMVR
Clinically symtomatic
and no improvement or
worsened MR
Clinically symtomatic
and no improvement or
worsened MR
‡ assuming a higher peri-operative risk
Nombela-Franco et al, JACC 2014

77. Symtomatic Severe Aortic Stenosis
SURGICAL
RISK Low/Intermediate High Prohibitive
MR
SEVERITY
None/Mild Moderate* Severe None/Mild Moderate* Severe None/Mild Moderate* Severe
SAVR
vs
TAVR
Double
Valve
intervention ‡
MR
MECHANISM
Functional Organic
LIKELIHOOD
IMPROVEMENT†
High Low
TREATMENT TAVR Medical therapy
vs.
TAVR
Potential evaluation of
Mitraclip or TVMR
Functional Organic Functional Organic
High Low
TAVR
vs.
Medical therapy
TAVR
vs
SAVR
TAVR Surgical Double
Valve
Intervention ‡
or
TAVR
Functional Organic
Potential evaluation of
Mitraclip or TMVR
Clinically symtomatic
and no improvement or
worsened MR
Clinically symtomatic
and no improvement or
worsened MR
‡ assuming a higher peri-operative risk
Nombela-Franco et al, JACC 2014

78. Symtomatic Severe Aortic Stenosis
SURGICAL
RISK Low/Intermediate High Prohibitive
MR
SEVERITY
None/Mild Moderate* Severe None/Mild Moderate* Severe None/Mild Moderate* Severe
SAVR
vs
TAVR
Double
Valve
intervention ‡
MR
MECHANISM
Functional Organic
LIKELIHOOD
IMPROVEMENT†
High Low
TREATMENT TAVR Medical therapy
vs.
TAVR
Potential evaluation of
Mitraclip or TVMR
Functional Organic Functional Organic
High Low
TAVR
vs.
Medical therapy
TAVR
vs
SAVR
TAVR Surgical Double
Valve
Intervention ‡
or
TAVR
Functional Organic
Potential evaluation of
Mitraclip or TMVR
Clinically symtomatic
and no improvement or
worsened MR
Clinically symtomatic
and no improvement or
worsened MR
‡ assuming a higher peri-operative risk
Nombela-Franco et al, JACC 2014

79. Symtomatic Severe Aortic Stenosis
SURGICAL
RISK Low/Intermediate High Prohibitive
MR
SEVERITY
None/Mild Moderate* Severe None/Mild Moderate* Severe None/Mild Moderate* Severe
SAVR
vs
TAVR
Double
Valve
intervention ‡
MR
MECHANISM
Functional Organic
LIKELIHOOD
IMPROVEMENT†
High Low
TREATMENT TAVR Medical therapy
vs.
TAVR
Potential evaluation of
Mitraclip or TVMR
Functional Organic Functional Organic
High Low
TAVR
vs.
Medical therapy
TAVR
vs
SAVR
TAVR Surgical Double
Valve
Intervention ‡
or
TAVR
Functional Organic
Potential evaluation of
Mitraclip or TMVR
Clinically symtomatic
and no improvement or
worsened MR
Clinically symtomatic
and no improvement or
worsened MR
‡ assuming a higher peri-operative risk
Nombela-Franco et al, JACC 2014

80. Jun-2014 -> Dic-2016 HEART TEAM

83. Cortes et al, JACC Interv 2016

84. Cortes et al, JACC Interv 2016
16%

85. Cortes et al, JACC Interv 2016
16%
58%

86. Cortes et al, JACC Interv 2016
16%
58%
9.6%

87. Cortes et al, JACC Interv 2016
16%
58%
9.6%
14.3%

88. Datos demográficos
• Edad: 78 years
• Sexo: Female
• Peso 46kg, BMI: 19
Antecedentes
• HTA, DL
• FA crónica con ACO
• Infarto lacunar (2003), AITx3 y estenosis carótidea
intervenida.
• Cardiopatía isquémica: DAp stent
• Insuficiencia renal (eGFR:45ml/min)
• Metrorragias de repetición
• Protesis rodilla derecho
• Asma bronquial con 2 ingresos por broncoespasmo
Presentación clínica
• Ingreso por ICC descompensada
Ecocardiograma TT:
• FEVI: 60%
• Estenosis aórtica severa (grad max/med
75/40mmHg)
• Insuficiencia mitral moderada degenerativa.
• Sin datos de hipertensión pulmonar.
Tratamiento:
• Sintrom, ASA, furosemide, Inhaladores.
Caso Clínico 2
Situación basal:
• Vive con su marido. Fried 3/5.

89. Datos demográficos
• Edad: 78 years
• Sexo: Female
• Peso 46kg, BMI: 19
Antecedentes
• HTA, DL
• FA crónica con ACO
• Infarto lacunar (2003), AITx3 y estenosis carótidea
intervenida.
• Cardiopatía isquémica: DAp stent
• Insuficiencia renal (eGFR:45ml/min)
• Metrorragias de repetición
• Protesis rodilla derecho
• Asma bronquial con 2 ingresos por broncoespasmo
Presentación clínica
• Ingreso por ICC descompensada
Ecocardiograma TT:
• FEVI: 60%
• Estenosis aórtica severa (grad max/med
75/40mmHg)
• Insuficiencia mitral moderada degenerativa.
• Sin datos de hipertensión pulmonar.
Tratamiento:
• Sintrom, ASA, furosemide, Inhaladores.
Caso Clínico 2
Situación basal:
• Vive con su marido. Fried 3/5. HEART TEAM
Doble recambio valvular + Cierre de orejuela

90. Caso Clínico 2
C-E Perimount Magna Ease 19mm
FA bloqueada -> Marcapasos VVI

91. Caso Clínico 2
C-E Perimount Magna Ease 19mm
FA bloqueada -> Marcapasos VVI

92. Caso Clínico 2
C-E Perimount Magna Ease 19mm
FA bloqueada -> Marcapasos VVI

93. Caso Clínico 2
C-E Perimount Magna Ease 19mm
FA bloqueada -> Marcapasos VVI

94. Caso Clínico 2
C-E Perimount Magna Ease 19mm
FA bloqueada -> Marcapasos VVI

95. Caso Clínico 2
Cierre de Orejuela+CIV

96. Caso Clínico 2
Cierre de Orejuela+CIV

97. Caso Clínico 2
Cierre de Orejuela+CIV

98. Caso Clínico 2
Un 1.5 años después de la cirugía, 2 ingresos por ICC

99. Caso Clínico 2
Un 1.5 años después de la cirugía, 2 ingresos por ICC

100. Caso Clínico 2
Un 1.5 años después de la cirugía, 2 ingresos por ICC

101. Caso Clínico 2
Un 1.5 años después de la cirugía, 2 ingresos por ICC

102. Caso Clínico 2
Un 1.5 años después de la cirugía, 2 ingresos por ICC

103. Caso Clínico 2
Tratamiento percutáneo de la Insuficiencia Mitral con Mitraclip

104. Caso Clínico 2
Tratamiento percutáneo de la Insuficiencia Mitral con Mitraclip

105. Caso Clínico 2
Tratamiento percutáneo de la Insuficiencia Mitral con Mitraclip

106. Caso Clínico 2
Tratamiento percutáneo de la Insuficiencia Mitral con Mitraclip

107. Mitral Valves
Aortic Valves
Mitral Repair

108. CONCLUSIONES
● La insuficiencia mitral significativa es frecuente en los pacientes TAVI (~20-30%).

109. CONCLUSIONES
● La insuficiencia mitral significativa es frecuente en los pacientes TAVI (~20-30%).
● La IM se asocia a mayor mortalidad precoz y a medio plazo, aunque hay mucha
variabilidad entre las diferentes series y podría existir un efecto de clase según las
válvulas. ¿Predictor independiente de mortalidad?.

110. CONCLUSIONES
● La insuficiencia mitral significativa es frecuente en los pacientes TAVI (~20-30%).
● La IM se asocia a mayor mortalidad precoz y a medio plazo, aunque hay mucha
variabilidad entre las diferentes series y podría existir un efecto de clase según las
válvulas. ¿Predictor independiente de mortalidad?.
● La severidad de la IM mejora en más del 50% de los pacientes, y parece asociarse a
mejor supervivencia.

111. CONCLUSIONES
● La insuficiencia mitral significativa es frecuente en los pacientes TAVI (~20-30%).
● La IM se asocia a mayor mortalidad precoz y a medio plazo, aunque hay mucha
variabilidad entre las diferentes series y podría existir un efecto de clase según las
válvulas. ¿Predictor independiente de mortalidad?.
● La severidad de la IM mejora en más del 50% de los pacientes, y parece asociarse a
mejor supervivencia.
● Muchas incognitas para predecir que pacientes son lo que van a mejorar.

112. CONCLUSIONES
● La insuficiencia mitral significativa es frecuente en los pacientes TAVI (~20-30%).
● La IM se asocia a mayor mortalidad precoz y a medio plazo, aunque hay mucha
variabilidad entre las diferentes series y podría existir un efecto de clase según las
válvulas. ¿Predictor independiente de mortalidad?.
● La severidad de la IM mejora en más del 50% de los pacientes, y parece asociarse a
mejor supervivencia.
● Muchas incognitas para predecir que pacientes son lo que van a mejorar.
● Sin duda, un tratamiento percutáneo de reparación y reemplazo mitral será una
opción para estos pacientes de alto riesgo y sintomáticos tras la TAVI. (Doble
tratamiento valvular percutáneo)