Multiple Valvular Heart Disease in the Transcatheter Era: A State-of-the-Art Review

Figures

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  Figure 1. Factors for expected MR improvement after isolated aortic valve replacement. This figure lists factors that are associated with MR regression (and lack of regression) after isolated aortic valve therapy in patients with combined aortic stenosis and mitral regurgitation. The blue box lists certain features that require more investigation (i.e., Do post-TAVR conduction disturbances increase risk of MR persistence?). Abbreviations: AV, aortic valve; LBBB, left bundle branch block; LVEDD, left ventricular end diastolic diameter; LVESD, left ventricular end systolic diameter; MR, mitral regurgitation; PVL, paravalvular leak; SAR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement.

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  Figure 2. Treatment algorithm for severe AS and MR. This figure describes an algorithm for the management of combined aortic stenosis and mitral regurgitation in the high-risk surgical patient. When MR is not expected to improve after TAVR, the option is for double-valve surgery (high-risk) vs. the TAVR first approach. In cases where TAVR is performed and there is severe residual MR, there are options for m-TEER (preferred) vs. other isolated mitral valve therapy options (i.e., transcatheter mitral valve replacement or minimally invasive mitral valve surgery). Abbreviations: AS, aortic stenosis; MR, mitral regurgitation; TAVR, transcatheter aortic valve replacement; m-TEER, mitral transcatheter edge-to-edge repair.

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  Figure 3. Factors favoring surgery or transcatheter approach in patients with severe aortic stenosis and tricuspid regurgitation. This figure illustrates the major factors favoring surgery or transcatheter approach in patients with severe aortic stenosis and TR. Abbreviations: LVEF, left ventricular ejection fraction; TR, tricuspid regurgitation.

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  Figure 4. Clinical and echocardiographic predictors for tricuspid regurgitation regression after m-TEER. This figure illustrates some of the known and unknown predictors for having residual tricuspid regurgitation after m-TEER. Abbreviations: CIED, cardiac implantable electronic device; MR, mitral regurgitation; m-TEER, mitral transcatheter edge-to-edge repair; PAP, pulmonary artery pressure; pHTN, pulmonary hypertension; RV, right ventricular; TMVR, transcatheter mitral valve replacement; TR, tricuspid regurgitation.

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  Figure 5. Example of combined mitral and tricuspid regurgitation cases. This figure illustrates variable cases of TR regression after m-TEER. Case #1 is an 80-year-old female with degenerative MR and severe TR with no resolution of TR despite successful m-TEER. Images on the left side show parasternal long-axis on transthoracic echocardiography with Doppler imaging showing severe mitral regurgitation prior to m-TEER (upper) and no MR after m-TEER (lower). On the right side is Doppler imaging of the tricuspid valve showing tricuspid regurgitation prior to m-TEER (upper) and no improvement in TR after m-TEER (lower). Case #2 is a 70-year-old male with functional MR, defibrillator, and severe TR who experienced improvement in TR after successful m-TEER. Images on the left side show parasternal long-axis on transthoracic echocardiography with Doppler imaging showing severe mitral regurgitation prior to m-TEER (upper) and trace MR after m-TEER (lower). On the right side, Doppler imaging of the tricuspid valve reveals severe tricuspid regurgitation prior to m-TEER (upper) and significant improvement in TR after m-TEER (lower). Abbreviations: MR, mitral regurgitation; m-TEER, mitral transcatheter…

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  Figure 6. Algorithm for mitral and tricuspid regurgitation. This figure shows an algorithm for the approach to combined mitral and tricuspid regurgitation in a high-surgical-risk patient. Abbreviation: m-TEER, mitral transcatheter edge-to-edge repair.

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  Figure 7. Considerations for surgery vs. transcatheter approach for concomitant aortic and mitral insufficiency. The figure describes factors that favor each approach to combined aortic and mitral insufficiency: 1) double valve surgery; 2) transcatheter aortic valve intervention before addressing the mitral insufficiency; and 3) transcatheter mitral valve treatment before addressing the aortic insufficiency. Abbreviations: AI, aortic insufficiency; MR, mitral regurgitation; m-TEER, mitral transcatheter edge-to-edge repair.

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  Figure 8. Expected tricuspid regurgitation regression after isolated mitral stenosis treatment. This figure illustrates factors in which tricuspid regurgitation regression is expected vs. not expected after isolated mitral valve therapy in patients with combined mitral stenosis and tricuspid regurgitation. Abbreviation: TR, tricuspid regurgitation.