(P098) THE EMERGING ROLE OF COMBINED TRANSCATHETER MULTIVALVE INTERVENTIONS - A SYSTEMATIC REVIEW

Background: Treatment strategies for multivalve disease remain uncertain due to a noticeable gap in guideline-based recommendations. Elevated mortality rates of double valve surgery prompted the emergence of percutaneous valve interventions. This review synthesizes the evidence on transcatheter interventions for the most frequent combinations of valve pathology: mitral regurgitation (MR) with aortic stenosis (AS) and MR with tricuspid regurgitation (TR).

METHODS AND RESULTS: PubMed/MEDLINE were searched until February 2024. Relevant studies were identified through title screening and snowballing references of included articles.

MR and AS
Persistent significant MR after transcatheter aortic valve replacement (TAVR) carries an increased mortality risk. A registry analysis demonstrated that TAVR patients with residual significant MR who underwent staged transcatheter mitral valve intervention (TMVI) had a lower mortality rate than those treated medically. The data on feasibility and safety of concomitant transcatheter mitral valve intervention (TMVI) and TAVR remains however scarce and conflicting. A report of 627 patients undergoing TAVR demonstrated no significant difference in hospital mortality in patients who underwent TMVI during the index or subsequent hospitalization (p=0.12). In-hospital complication rates, however, were significantly higher in the former probably a result of multimorbidity and cardiogenic shock. In contrast, Sagheer et al. demonstrated that TAVR patients who underwent TMVI during the index hospitalization had significantly higher hospital mortality rates than those who underwent the procedure during a subsequent hospitalization (p=0.04).
Considering the limitations of retrospective studies, for patients who continue to have significant MR post-TAVR, TMVI should be recommended and is feasible to perform either during the index hospitalization or as a scheduled post-discharge procedure. Clinical status and comorbidities play an important role in outcomes.

MR and TR
Secondary TR post TMVI carries an increased mortality risk. Although timing and outcomes of surgical tricuspid valve repair are often debatable, it is even more so for transcatheter tricuspid valve interventions. A pooled analysis of 2 nonrandomized registries (TriValve and TRAMI) suggested a two-fold reduction in adjusted mortality (p=0.035) for patients who underwent combined transcatheter mitral/tricuspid valve interventions (TMTVI) as opposed to isolated TMVI in the setting of significant TR. Currently, data on combined TMTVI is limited and randomized studies should be pursued.

Conclusion: Despite increasing interest in multivalve interventions, evidence remains scarce. Multivalve interventions are often performed in patients with high baseline mortality – as a “last-ditch” effort. Further studies are required to refine patient selection, to determine optimal timing of intervention and to compare the advantages of simultaneous versus sequential procedures.