Reoperative Mitral Valve Replacement versus Transcatheter Valve-in-Valve and Valve-in-Ring Procedures in High-Risk Patients

Background: Reoperative mitral valve replacement (redo-MVR) after former ring annuloplasty or bioprosthetic valve implantation is believed to be a high risk procedure, especially in elderly patients. Transcatheter mitral valve-in-valve or valve-in-ring (ViV/ViR) procedures are an increasingly performed alternative. We aimed to compare clinical outcomes after both procedures.

Method: All patients ≥50 years of age, treated for degenerated mitral bioprostheses or failed annuloplasty rings between 2000 and 2022 at our center, were included. Patients with mechanical valves or valve endocarditis were excluded. This yielded 15 patients in each cohort (n = 30). Outcomes were compared on behalf of the mitral valve academic research consortium (MVARC) endpoint definitions.

Results: ViV/ViR patients were significantly older (76.9 ± 5.8 years ViV/ViR vs. 68.0 ± 8.4 years, p < 0.01). EuroSCORE II was 12.0% ± 2.9 versus 10.0% ± 2.7 (p = 0.06). ViV/ViR access route was transfemoral in 46.7% (7/15) and transapical in 53.3% (8/15). In Redo-MVR, access was via resternotomy in 93.3% (14/15) and via anterolateral minithoracotomy in 6.7% (1/15). Implanted valve size was smaller in ViV/ViR (28.2 ± 1.4 mm vs. 29.5 ± 1.8 mm; p = 0.03). Rate of technical success according to MVARC criteria was 73.3% (11/15, ViV/ViR) versus 86.7% (13/15, Redo-MVR; p = 0.65). Rate of device success was lower in ViV/ViR, being 40.0% (6/15) versus 86.7% (13/15, p = 0.02), which was mainly driven by elevated gradients, as gradients were higher after ViV/ViR (5.9 ± 1.5 mm Hg vs. 4.9 ± 0.8 mm Hg, p = 0.04). No patient had moderate or severe mitral regurgitation at discharge (p = 1.00). 30-day mortality was 6.7% (1/15) versus 0% (p = 1.00). Strokes occurred in 6.7% (1/15) in each group (p = 1.00). Kaplan–Meier survival rates at 1 and 2 years were 85.6 versus 92.3% and 85.6 versus 70.3%, respectively (p = 0.72). Rate of cardiac-related rehospitalization and rate of patients being in NYHA class I/II at follow-up was not significantly different (p = 1.00).

Conclusion: In this small high-risk cohort of patients, mortality after both procedures was lower than expected and comparable between the cohorts. However, ViV/ViR led to implantation of smaller prostheses, which resulted in significantly higher gradients. The clinical significance of this in the long-term is yet to be determined, as mid-term survival was similar.

Publikationsverlauf

Artikel online veröffentlicht:
28. Januar 2023