New or worsened mitral regurgitation (MR) is an uncommon yet serious complication after surgical aortic valve replacement (SAVR). While there have been numerous reports of its occurrence, there is little consensus regarding its presentation and management. This systematic review summarizes the evidence in the current literature surrounding new or worsened MR after SAVR and analyzes its potential implications.
Methods
Databases were examined for all articles and abstracts reporting on new or worsened MR after SAVR. Data collected included number of patients studied; patient characteristics; incidences of new or worsened MR; timing of diagnosis; and treatment.
Results
Thirty-six full-text citations were included in this review. The prevalence of new or worsened MR after SAVR was 8.4%. Sixteen percent of new MR occurrences were from an organic etiology, and 83% of new MR occurrences were that of a functional etiology. Most diagnoses were made in the late or unspecified postoperative period using echocardiography (range: 0 minutes to 18 years postoperatively). While no patients died from this complication, 7.7% of patients (16 out of 207) required emergent procedural re-intervention.
Conclusions
This systematic review underscores the importance of identifying new or worsened MR following SAVR and accurate scoring of MR severity to guide treatment. It also outlines the associated clinical measures commonly documented following this complication, and the usefulness of transesophageal echocardiography for the detection of significant MR. These results reflect the current, limited state of the literature on this topic and warrant further investigation into MR detection and management strategies in SAVR patients.
BarreiroCJPatelNDFittonTP, et al. Aortic valve replacement and concomitant mitral valve regurgitation in the elderly: impact on survival and functional outcome. Circulation. 2005;112(9 suppl):I443-I447. doi:10.1161/circulationaha.104.526046
2.
BraschAVKhanSSDeRobertisMAKongJHChiuJSiegelRJ.Change in mitral regurgitation severity after aortic valve replacement for aortic stenosis. Am J Cardiol. 2000;85:1271-1274.
3.
EssandohMOteyABhandarySCrestanelloJ.Severe mitral regurgitation complicating minimally invasive aortic valve replacement: is it functional or organic?J Cardiothorac Vasc Anesth. 2015;29:1743-1750. doi:10.1053/j.jvca.2015.07.016
4.
Caballero-BorregoJGomez-DoblasJJCabrera-BuenoF, et al. Incidence, associated factors and evolution of non-severe functional mitral regurgitation in patients with severe aortic stenosis undergoing aortic valve replacement. Eur J Cardiothorac Surg. 2008;34:62-66. doi:10.1016/j.ejcts.2008.03.055
5.
Tassan-ManginaSMetzDNazeyllasP, et al. Factors determining early improvement in mitral regurgitation after aortic valve replacement for aortic valve stenosis: a transthoracic and transesophageal prospective study. Clin Cardiol. 2003;26:127-131.
6.
AdamsPBOttoCM.Lack of improvement in coexisting mitral regurgitation after relief of valvular aortic stenosis. Am J Cardiol. 1990;66:105-107.
7.
MoazamiNDiodatoMDMoonMR, et al. Does functional mitral regurgitation improve with isolated aortic valve replacement?J Card Surg. 2004;19:444-448. doi:10.1111/j.0886-0440.2004.00362.x
8.
MoherDLiberatiATetzlaffJAltmanDG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151:264-269.
9.
ACarpentierDAdamsFFilsoufi, eds. Valve analysis: the functional classification. In: Carpentier’s Reconstructive Valve Surgery. From Valve Analysis to Valve Reconstruction. Saunders Elsevier; 2010:5-10.
10.
ShabsighMLawrenceCRosero-BrittonBR, et al. Mitral valve stenosis after open repair surgery for non-rheumatic mitral valve regurgitation: a review. Front Cardiovasc Med. 2016;3:8.
11.
AttizzaniGFOhnoYLatibA, et al. Transcatheter aortic valve implantation under angiographic guidance with and without adjunctive transesophageal echocardiography. Am J Cardiol. 2015;116:604-611.
12.
WellsGSheaBO’ConnellD, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Ottawa Hospital Research Institute; 2009.
KumarNEssandohMBhattA, et al. Pulmonary cuff dysfunction after lung transplant surgery: a systematic review of the evidence and analysis of its clinical implications. J Heart Lung Transplant. 2019;38:530-544.
15.
IslamogluFApaydinAZDegirmencilerKGurgunCDurmazI.Detachment of the mitral valve anterior leaflet as a complication of aortic valve replacement. Tex Heart Inst J. 2006;33:54-56.
16.
VelascoSLarmanMEnerizM.Percutaneous closure of a native mitral valve perforation. Rev Esp Cardiol. 2010;63:597.
17.
AgrawalDAngKLMittalTPrasadS.Mitral valve injury by cardiotomy suction during aortic valve replacement—a near miss. Interact Cardiovasc Thorac Surg. 2008;7:136-137. doi:10.1510/icvts.2007.158865
18.
CelikMGunerAKilicgedikA, et al. A rare complication of mechanical aortic valve replacement: separation in the region of the mitral-aortic intervalvular fibrosa. Echocardiography. 2017;34:1232-1233. doi:10.1111/echo.13629
19.
MaddaliMMWajeNDKandacharPSAl AjmiWAAMohamedB.Rare cause of new mitral regurgitation after aortic valve replacement. J Cardiothorac Vasc Anesth. 2016;30:845-847. doi:10.1053/j.jvca.2015.09.014
20.
PagelPSKhotimskyI.New complex mitral regurgitation after aortic valve replacement: iatrogenic injury or simple explanation?J Cardiothorac Vasc Anesth. 2014;28:1429-1431. doi:10.1053/j.jvca.2013.10.003
21.
SteimanJChaneyMA.Iatrogenic mitral valve injury during aortic valve replacement: importance of intraoperative transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2011;25:586.
22.
Arat-OzkanAOkcunBMertMBaranTKucukogluS.Tear in mitral anterior leaflet as a complication of Manouguian’s procedure in a woman with an aortic valve prosthesis. J Heart Valve Dis. 2004;13:630-631.
23.
van GorselenENihoyannopoulosPVerhorstPvon BirgelenCPrendergastBBellamyM. Severe regurgitation due to perforation of the mitral-aortic intervalvular fibrosa 3 years after aortic valve replacement. Eur J Echocardiogr. 2011;12:E30. doi:10.1093/ejechocard/jer007
24.
den UilCAter HorstMAkinSGalemaTW.Severe systolic anterior motion after aortic valve replacement and Cox MAZE surgery. J Card Surg. 2016;31:429-431.
25.
DohiMDoiKOkawaKYamanamiMYakuH.Delayed-onset systolic anterior motion of the mitral valve after aortic valve replacement for severe aortic stenosis. Int Heart J. 2013;54:292-296.
26.
FukuiSMitsunoMYamamuraM, et al. Left ventricular outflow tract obstruction masked by severe aortic stenosis. Gen Thorac Cardiovasc Surg. 2017;65:160-163.
27.
JooHCChangBCChoSHYounYNYooKJLeeS.Fate of functional mitral regurgitation and predictors of persistent mitral regurgitation after isolated aortic valve replacement. Ann Thorac Surg. 2011;92:82-87.
28.
KadirogullariEOnanBGulerSErkanliK.Perforation of the anterior mitral leaflet after aortic valve replacement with root enlargement. Ann Thorac Surg. 2017;104:e345-e346.
29.
KasaharaHInoueYSuzukiSHayashiI.Pseudo systolic anterior motion: potential for severe mitral regurgitation after aortic valve replacement. Ann Thorac Cardiovasc Surg. 2014;20:329-331.
30.
KerutEKHanawaltCDearstineMFrankREversonC.Mitral systolic anterior motion (SAM) with dynamic left ventricular outflow obstruction following aortic valve replacement. Echocardiography. 2007;24:658-660.
SchubertSAYarboroLTMadalaS, et al. Natural history of coexistent mitral regurgitation after aortic valve replacement. J Thorac Cardiovasc Surg. 2016;151:1032-1039, 1042.e1.
33.
SukernikMRSumnerADPaeWE.Systolic anterior motion of the mitral valve after aortic valve replacement for aortic insufficiency. J Cardiothorac Vasc Anesth. 2007;21:574-576.
34.
UcakAOnanBInanKKaracaOGUgurMYilmazAT.Detachment of an annular patch following the Manougian procedure. J Card Surg. 2010;25:291-292.
35.
Van Der MerweJCoddensJCasselmanF. Acute single leaflet dysfunction and spontaneous recovery of a previously implanted bi-leaflet mechanical mitral prosthesis during unrelated isolated minimally invasive aortic valve replacement: a surgical decision making dilemma in a high risk patient. J Cardiovasc Surg (Torino). 2017;58:131-132.
36.
EyndenFVBouchardDEl-HamamsyI, et al. Effect of aortic valve replacement for aortic stenosis on severity of mitral regurgitation. Ann Thorac Surg. 2007;83:1279-1284.
37.
WanCKSuriRMLiZ, et al. Management of moderate functional mitral regurgitation at the time of aortic valve replacement: is concomitant mitral valve repair necessary?J Thorac Cardiovasc Surg. 2009;137:635-640.e1.
38.
ScanduraSUssiaGPCaggegiA, et al. Percutaneous mitral valve repair in patients with prior cardiac surgery. J Card Surg. 2012;27:295-298.
39.
ZakiJFMarkhamTChoiWMoiseOAijaziMSheinbaumR.Systolic Anterior Motion of the Mitral Valve After Aortic Valve Replacement. Taylor & Francis; 2018:203-204.
40.
BeckermanZMcPhersonLChenEP.Interrupted aortic arch in a patient with patient-prosthesis mismatch after aortic valve replacement. Aorta (Stamford). 2019;7:140-143.
41.
WakabayashiRIdeSIshidaTTanakaSKawamataM.Severe mitral regurgitation due to geometric changes in the mitral valve after surgical aortic valve replacement. JA Clin Rep. 2019;5:59.
42.
ErolMEÖzyalçinSKocabeyoğluSSVuralK. The effect of patient prosthesis mismatch on functional mitral regurgitation in patients with mechanical aortic valve replacement. Koşuyolu Heart J. 2020;23:22-26.
43.
SqueriAFerriACalviS, et al. P752 Mitral regurgitation in patients with severe aortic stenosis: role of valvular calcification in the persistence of mitral regurgitation after aortic valve replacement. Eur Heart J Cardiovasc Imaging. 2020;21(suppl 1):jez319.416.
44.
Navas-BlancoJRCookSAGuerra-LondonoCBorgiJSandersJASzymanskiTJ.Severe mitral regurgitation due to a “folded” anterior mitral valve leaflet after Bentall procedure requiring mitral valve replacement. J Cardiothorac Vasc Anesth. 2018;32:1337-1340. doi:10.1053/j.jvca.2017.08.045
45.
ImanakaKTakamotoSFuruseA.Mitral regurgitation late after Manouguian’s anulus enlargement and aortic valve replacement. J Thorac Cardiovasc Surg. 1998;115:727-729. doi:10.1016/s0022-5223(98)70342-3
46.
ImanakaKFuruseAMurakawaTNakajimaJKozukaYYagyuK.Reoperation for mitral regurgitation 13 years after aortic valve replacement and manouguian’s anulus enlargement: report of a case [in Japanese]. Kyobu Geka. 1997;50:1101-1103.
47.
LeeTMittnachtAJCItagakiSStewartA.Mitral regurgitation exacerbation due to sutureless aortic valve replacement. Ann Thorac Surg. 2018;105:e103-e105. doi:10.1016/j.athoracsur.2017.10.001
48.
FutamiMKurodaMKawamotoM.Severe mitral regurgitation associated with systolic anterior motion of mitral valve occurring after aortic valve replacement and myectomy for aortic stenosis and hypertrophic obstructive cardiomyopathy [in Japanese]. Masui. 2010;59:635-640.
49.
Van DyckMGlineurDde KerchoveLEl KhouryG. Complications after aortic valve repair and valve-sparing procedures. Ann Cardiothorac Surg. 2013;2:130-139. doi:10.3978/j.issn.2225-319X.2012.12.03
50.
NelsonJAEspinosaRMichelenaHRehfeldtK.Acute severe functional mitral regurgitation after non-mitral valve cardiac surgery—left ventricular dyssynchrony as a potential mechanism. J Cardiothorac Vasc Anesth. 2021;35:1292-1298. doi:10.1053/j.jvca.2020.08.045
51.
ManouguianSSeybold-EptingW.Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet: new operative technique. J Thorac Cardiovasc Surg. 1979;78:402-412.
52.
OkabeHAsanoKMizunoA, et al. Clinical and anatomical evaluations of Manouguian’s procedure [in Japanese]. Nihon Kyobu Geka Gakkai Zasshi. 1986;34:1884-1891.
53.
DumaniSLikajEDibraLBecaVKuciSRefatllariA.Aortic annulus enlargement: early and long-terms results. Open Access Maced J Med Sci. 2017;5:23-26.
54.
DemïrtürkOSKiziltanHTCoşkunİTünelHATekinHG.Long-term results of pericardial autologous patch enlargement of the aortic annulus using the Manouguian technique. Heart Surg Forum. 2016;19:E067-E073.
55.
DumaniSLikajEDibraLLlazoSRefatllariA.Aortic annular enlargement during aortic valve replacement. Open Access Maced J Med Sci. 2016;4:455-457.
56.
KulikAAl-SaighMChanV, et al. Enlargement of the small aortic root during aortic valve replacement: is there a benefit?Ann Thorac Surg. 2008;85:94-100.
57.
KitamuraMSatohMHachidaMEndoMHashimotoAKoyanagiH.Aortic valve replacement in small aortic annulus with or without annular enlargement. J Heart Valve Dis. 1996;5(suppl 3):S289-S293.
58.
Nombela-FrancoLRibeiroHBUrenaM, et al. Significant mitral regurgitation left untreated at the time of aortic valve replacement: a comprehensive review of a frequent entity in the transcatheter aortic valve replacement era. J Am Coll Cardiol. 2014;63:2643-2658. doi:10.1016/j.jacc.2014.02.573
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