A three-dimensional echocardiographic study on aortic-mitral coupling in transcatheter aortic valve replacement

Eur Heart J Cardiovasc Imaging. 2013 Oct;14(10):950-6. doi: 10.1093/ehjci/jet058. Epub 2013 May 29.


Aims: Normal aortic valve (AV) and mitral valve (MV) function in a reciprocal interdependent fashion. We hypothesized that MV function would be affected by severe aortic stenosis (AS) and that it would remain altered after transcatheter AV replacement (TAVR). Using three-dimensional (3D) echocardiography, we studied aortic-mitral coupling in patients with severe AS undergoing TAVR and compared them with controls.

Methods and results: Three-dimensional transoesophageal echocardiography (Philips iE33) was performed on 43 patients: 27 with severe AS studied pre- and post-TAVR and 16 controls. A custom software tracked the aortic annulus (AoA) and mitral annulus (MA), allowing dynamic automated measurements of AoA and MA morphology, angle, and motion. The AS pre-TAVR patients had significantly reduced MA displacement, MA area, and maximum AoA area compared with the controls. Post-TAVR, MA displacement, MA area, and AoA area remained reduced. End-systolic AoA-MA angle was significantly wider in the AS patients compared with the controls and remained wider post-TAVR. Pre-TAVR, there was no difference in MA or AoA dynamics between patients with mild vs. moderate-to-severe MA calcium; Edwards-Sapien vs. a Medtronic CoreValve valve; normal vs. reduced left ventricular systolic function whereas post-TAVR, MA dynamics were significantly reduced in those with moderate-to-severe MA calcium.

Conclusion: This is the first study to demonstrate that AS can affect a secondary 'unaffected' valve, the MV, due to the calcification in the aortic-mitral fibrous continuity. TAVR does not result in recovery of MV structure. These changes have implications in the future TAVR valve development and the possible need for MV assessment pre- and post-TAVR.

Keywords: aortic stenosis; aortic–mitral coupling; three-dimensional echocardiography; transcatheter aortic valve replacement.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Aortic Valve Stenosis / diagnostic imaging*
  • Aortic Valve Stenosis / surgery*
  • Cardiac Catheterization / methods
  • Case-Control Studies
  • Echocardiography, Three-Dimensional / methods*
  • Echocardiography, Transesophageal*
  • Female
  • Follow-Up Studies
  • Heart Valve Prosthesis
  • Heart Valve Prosthesis Implantation / methods*
  • Humans
  • Male
  • Minimally Invasive Surgical Procedures / methods
  • Mitral Valve / diagnostic imaging*
  • Mitral Valve / physiopathology
  • Reference Values
  • Risk Assessment
  • Severity of Illness Index
  • Treatment Outcome