Transcatheter Mitral Valve Replacement After Surgical Repair or Replacement
Authors: Matheus Simonato, Brian Whisenant, Henrique Barbosa Ribeiro, John G. Webb, Ran Kornowski, Mayra Guerrero, Harindra Wijeysundera, Lars Søndergaard, Ole De Backer, Pedro Villablanca, Charanjit Rihal, Mackram Eleid, Jörg Kempfert, Axel Unbehaun, Magdalena Erlebach, Filip Casselman, Matti Adam, Matteo Montorfano, Marco Ancona, Francesco Saia, Timm Ubben, Felix Meincke, Massimo Napodano, Pablo Codner, Joachim Schofer, Marc Pelletier, Anson Cheung, Mony Shuvy, José Honório Palma, Diego Felipe Gaia, Alison Duncan, David Hildick-Smith, Verena Veulemans, Jan-Malte Sinning, Yaron Arbel, Luca Testa, Arend de Weger, Helene Eltchaninoff, Thibault Hemery, Uri Landes, Didier Tchetche, Nicolas Dumonteil, Josep Rodés-Cabau, Won-Keun Kim, Konstantinos Spargias, Panagiota Kourkoveli, Ori Ben-Yehuda, Rui Campante Teles, Marco Barbanti, Claudia Fiorina, Arun Thukkani, G. Burkhard Mackensen, Noah Jones, Patrizia Presbitero, Anna Sonia Petronio, Abdelhakim Allali, Didier Champagnac, Sabine Bleiziffer, Tanja Rudolph, Alessandro Iadanza, Stefano Salizzoni, Marco Agrifoglio, Luis Nombela-Franco, Nikolaos Bonaros, Malek Kass, Giuseppe Bruschi, Nicolas Amabile, Adnan Chhatriwalla, Antonio Messina, Sameer A. Hirji, Martin Andreas, Robert Welsh, Wolfgang Schoels, Farrel Hellig, Stephan Windecker, Stefan Stortecky, Francesco Maisano, Gregg W. Stone, Danny Dvir
Journal: Circulation (2020)

Mitral valve-in-valve (ViV) and valve-in-ring (ViR) are alternatives to surgical reoperation in patients with recurrent mitral valve failure after previous surgical valve repair or replacement. Our aim was to perform a large-scale analysis examining midterm outcomes after mitral ViV and ViR.Patients undergoing mitral ViV and ViR were enrolled in the Valve-in-Valve International Data Registry. Cases were performed between March 2006 and March 2020. Clinical endpoints are reported according to the Mitral Valve Academic Research Consortium (MVARC) definitions. Significant residual mitral stenosis (MS) was defined as mean gradient ≥10 mm Hg and significant residual mitral regurgitation (MR) as ≥ moderate.A total of 1079 patients (857 ViV, 222 ViR; mean age 73.5±12.5 years; 40.8% male) from 90 centers were included. Median STS-PROM score 8.6%; median clinical follow-up 492 days (interquartile range, 76-996); median echocardiographic follow-up for patients that survived 1 year was 772.5 days (interquartile range, 510-1211.75). Four-year Kaplan-Meier survival rate was 62.5% in ViV versus 49.5% for ViR (P<0.001). Mean gradient across the mitral valve postprocedure was 5.7±2.8 mm Hg (≥5 mm Hg; 61.4% of patients). Significant residual MS occurred in 8.2% of the ViV and 12.0% of the ViR patients (P=0.09). Significant residual MR was more common in ViR patients (16.6% versus 3.1%; P<0.001) and was associated with lower survival at 4 years (35.1% versus 61.6%; P=0.02). The rates of Mitral Valve Academic Research Consortium-defined device success were low for both procedures (39.4% total; 32.0% ViR versus 41.3% ViV; P=0.01), mostly related to having postprocedural mean gradient ≥5 mm Hg. Correlates for residual MS were smaller true internal diameter, younger age, and larger body mass index. The only correlate for residual MR was ViR. Significant residual MS (subhazard ratio, 4.67; 95% CI, 1.74-12.56; P=0.002) and significant residual MR (subhazard ratio, 7.88; 95% CI, 2.88-21.53; P<0.001) were both independently associated with repeat mitral valve replacement.Significant residual MS and/or MR were not infrequent after mitral ViV and ViR procedures and were both associated with a need for repeat valve replacement. Strategies to improve postprocedural hemodynamics in mitral ViV and ViR should be further explored.