Surgical redo versus transseptal or transapical transcatheter mitral valve‐in‐valve implantation for failed mitral valve bioprosthesis

Abstract

Background Redo surgical mitral valve replacement (SMVR) is the current standard of care for patients with failed bioprosthetic mitral valve (MV). Transcatheter mitral valve‐in‐valve replacement (TMViV) is arising as an alternative to SMVR in high risk patients. We sought to evaluate procedural safety, early and mid‐term outcomes of patients who underwent transseptal TMViV (TS‐TMViV), transapical TMViV (TA‐TMViV), or redo‐SMVR. Methods We identified patients with failed bioprosthetic MV who underwent TS‐TMViV, TA‐TMViV, or SMVR at four Italian Centers. Clinical and echocardiographic data were codified according to Mitral Valve Academic Research Consortium definition (MVARC), except for significant valve stenosis. Results Between December 2012 and September 27, 2019 patients underwent TS‐TMViV, 22 TA‐TMViV, and 29 redo‐SMVR. TS‐TMViV and TA‐TMViV patients presented higher mean age and surgical risk scores compared with SMVR group (77.8 ± 12 years, 77.3 ± 7.3 years, 67.8 ± 9.4 years, p < .001; STS PROM 8.5 ± 7.2; 8.9 ± 4.7; 3.6 ± 2.6, p < .001). TS‐TMViV procedure was associated with shorter intensive care unit time and total length of stay (LOS) compared with TA‐TMViV and SMVR group. There were no differences in MVARC procedural success at 30‐days (74.1, 72.7, and 51.7%, p = .15) and one‐year all‐cause mortality between groups (14.8, 18.2, and 17.2%, p = 1.0). MV mean gradient was similar between TS‐TMViV, TA‐TMViV, and SMVR groups at 30 days and 12 months. Conclusions For the selected patients, TS‐TMViV and TA‐TMViV are to be considered a valid alternative to redo‐SMVR with comparable 1‐year survival. TS‐TMViV is the less invasive strategy and has the advantage of shortening the LOS compared with TA‐TMViV.

Mitral surgical redo versus transapical transcatheter mitral valve implantation

“…In accordance with the findings of previous studies, we discovered that both procedures provide comparable and excellent hemodynamic results with low transvalvular gradients at follow-up [ 9 , 11 , 22 ]. Follow-up echocardiography showed mean transvalvular gradients in the transcatheter arm of 4.2±0.8mmHg, compared to 3.9±1.2 mmHg in the surgical group.…”

“…Although, most of the TA-TMVR in our cohort were performed with a very small amount of contrast dye or even none at all, no significant difference was noted in postoperative new onset dialysis between the groups. Similar outcomes have also been reported by Simonetto et al [ 22 ]. We believe that thanks to the fluoroscopic qualities of prior implanted surgical mitral valve prostheses and mitral rings, the amount of contrast dye could be further reduced or completely excluded [ 5 ].…”

Left Ventricular Apex: A “Minimally Invasive Motorway” for Safe Cardiovascular Procedures

“…The success rate was lower and mortality rates and LVOT obstruction rates were higher in the valve-in-MAC group. Some authors report similar early and one-year clinical results among patients undergoing trans-septal, transapical mitral transcatheter ViV procedures and open surgical re-mitral valve replacement [27], while others find that the transeptal transcatheter approach is associated with lower overall 1-year mortality rates [28].…”

Transapical transcatheter mitral valve implantation in patients with degenerated mitral bioprostheses or failed ring annuloplasty

“…The thirty-day mortality observed in the present study is slightly lower as compared with the current literature reporting a thirty-day mortality of 13.6% (10). Compared to the percutaneous trans-septal approach, thirty-day mortality is inherently higher, as transapical patients usually come with more comorbidities such as peripheral artery disease (11,12). Moreover, in a study by Eleid et al, patients undergoing the valve-in-ring procedures were excluded from their analysis, as those patients seem to carry a higher periprocedural risk, namely paravalvular leakage and LVOT obstruction (12).…”