Aims Due to bioprosthetic valve degeneration, aortic valve-in-valve (ViV) procedures are increasingly performed. There are no data on long-term outcomes after aortic ViV. Our aim was to perform a large-scale assessment of long-term survival and reintervention after aortic ViV. Methods and results A total of 1006 aortic ViV procedures performed more than 5 years ago [mean age 77.7 ± 9.7 years; 58.8% male; median STS-PROM score 7.3% (4.2–12.0)] were included in the analysis. Patients were treated with Medtronic self-expandable valves (CoreValve/Evolut, Medtronic Inc., Minneapolis, MN, USA) (n = 523, 52.0%), Edwards balloon-expandable valves (EBEV, SAPIEN/SAPIEN XT/SAPIEN 3, Edwards Lifesciences, Irvine, CA, USA) (n = 435, 43.2%), and other devices (n = 48, 4.8%). Survival was lower at 8 years in patients with small-failed bioprostheses [internal diameter (ID) ≤ 20 mm] compared with those with large-failed bioprostheses (ID > 20 mm) (33.2% vs. 40.5%, P = 0.01). Independent correlates for mortality included smaller-failed bioprosthetic valves [hazard ratio (HR) 1.07 (95% confidence interval (CI) 1.02–1.13)], age [HR 1.21 (95% CI 1.01–1.45)], and non-transfemoral access [HR 1.43 (95% CI 1.11–1.84)]. There were 40 reinterventions after ViV. Independent correlates for all-cause reintervention included pre-existing severe prosthesis–patient mismatch [subhazard ratio (SHR) 4.34 (95% CI 1.31–14.39)], device malposition [SHR 3.75 (95% CI 1.36–10.35)], EBEV [SHR 3.34 (95% CI 1.26–8.85)], and age [SHR 0.59 (95% CI 0.44–0.78)]. Conclusions The size of the original failed valve may influence long-term mortality, and the type of the transcatheter valve may influence the need for reintervention after aortic ViV.

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Background: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed. Methods: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis. Results: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR −1.53 days, MiSuAVR −2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups. Conclusions: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

Background: Acute hemodynamic changes from the MitraClip (Abbott Vascular, Santa Clara, CA) procedure have been shown for mitral regurgitation (MR) from mixed etiology, but have not been elucidated in functional MR alone. Also, there is a misconception that reducing functional MR may lead to a detrimental change in acute hemodynamics. Methods: A retrospective review was performed on 85 consecutive patients with functional MR (mean age 76Ϯ11 years, 30 (35%) females) who had full set of hemodynamics prior to and after the MitraClip procedure. 57 (67%) patients were included in the high-risk registry (mean STS score 14.9Ϯ7.4%) with 78 (92%) in NYHA functional class III or IV and 77 (91%) with MR grade 4ϩ. There were 34 (40%) patients with left ventricular ejection fraction (LVEF) Յ 35% (mean 26Ϯ6%); overall mean left ventricular end systolic diameter of 40Ϯ10mm. Results: There were significant improvements in the cardiac index (CI; mean pre CI of 1.92Ϯ0.47 L/min/m2 vs. post CI 2.43Ϯ0.61 L/min/m2, pϽ0.001) and mean left atrial pressures (MLAP; mean pre MLAP of 20.7Ϯ6.7 mmHg vs. post MLAP 17.2Ϯ5.7 mmHg, pϽ0.001). Improvements in CI and MLAP was observed in 75/85 (88%) and 50/74 (68%) patients respectively. At a mean follow-up of 13Ϯ9months, 76/85 (89%) was in NYHA functional class I or II (from 78/85 (92%) in NYHA class III or IV at baseline, pϽ0.001) and 71/85 (84%) had MR grade Յ 2ϩ (from 85/85 (100%) in MR grade 3ϩ or 4ϩ at baseline, pϽ0.001). Conclusions: In patients with functional MR, the MitraClip procedure resulted in a significant change in CI and MLAP.

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