Multivalvular heart disease and outcomes after transcatheter aortic valve implantation: updated results from the MIRA study

Background Multivalvular heart disease (MVHD) is highly prevalent among patients undergoing transcatheter valve interventions and is consistently associated with impaired clinical outcomes. However, comprehensive data on the prognostic implication in this complex population remain limited. The aim of this study was to assess outcomes of patients with MVHD undergoing transcatheter aortic valve implantation (TAVI) according to concomitant valvular heart disease. Methods The Multi-valve Intervention Registry and Analysis (MIRA) is an investigator-initiated, retrospective, international, multicentre registry of consecutive patients with MVHD undergoing transcatheter valve interventions at eight centres in Germany, France, and the United States (2008–2024). MVHD was defined as ≥1 severe valvular lesion treated by first transcatheter intervention (aortic, mitral, or tricuspid) and ≥1 additional lesion of at least moderate severity. This analysis included patients undergoing TAVI for severe aortic stenosis (AS) with concomitant mitral regurgitation (MR) ≥2+ (ASMR), tricuspid regurgitation (TR) ≥2+ (ASTR), or both (ASMR+TR). Baseline characteristics, changes in MR and TR after TAVI, and 5-year outcomes were assessed. The primary endpoint was 5-year all-cause mortality. Results A total of 10,075 patients with MVHD undergoing transcatheter valve interventions were included in the MIRA study. Among these, 6,805 patients with severe AS undergoing TAVI were identified (ASMR: n=2,032; ASTR: n=967; ASMR+TR: n=3,806; Figure 1). Baseline characteristics showed significant differences between the groups. In general, patients in the ASMR+TR group had higher estimated surgical risk, were more symptomatic, higher rates of AF, and higher sPAP compared to the other groups. Patients in the ASTR group showed the highest rates of chronic lung disease, prior myocardial infarction, and prior pacemaker. Following TAVI, MR improved from ≥2+ to ≤1+ in 21.9% of patients with ASMR and 17.4% of patients with ASMR+TR. Improvement of concomitant TR from ≥2+ to ≤1+ occurred in 31.7% of patients with ASTR, and in 24.2% of patients with ASMR+TR. Kaplan-Meier analyses (Figure 2) demonstrated significantly higher 5-year all-cause mortality in patients with ASMR+TR (66% vs. 59% in the ASMR, and 60% in the ASTR group, p<0.001). Five-year mortality was not different between the groups of ASMR and ASTR (p=0.9). Conclusions This analysis of patients with MVHD undergoing TAVI highlights the impact of concomitant valvular lesions on outcomes after TAVI. The highest event rates were observed in patients with AS and combined MR and TR, in whom MR and TR improved less after TAVI, suggesting advanced myocardial damage and limited reversibility. In contrast, isolated MR or TR had a similar impact on 5-year outcomes. These findings support tailored management and careful preprocedural risk stratification in patients with MVHD.Figure 1Figure 2