TMVR Outcomes Acceptable for Failed Bioprosthetic Valves, Annuloplasty Rings

Transcatheter mitral valve replacement (TMVR) was successful in treating high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral valve-in-ring was associated with higher rates of procedural complications and mid-term mortality compared with mitral valve-in-valve procedures, according to a study published August 21 in the Journal of the American College of Cardiology.

Sung-Han Yoon, MD, et al., examined 248 patients with previous mitral valve surgery who were treated with TMVR. Of these, 176 patients had TMVR for degenerated mitral bioprosthetic valves, or valve-in –valve, and 72 patients had TMVR for failed annuloplasty rings, or valve-in-ring procedures. Surgical risk scores were similar between these two patient groups.

Overall, procedure-related death, conversion to conventional surgery, left ventricular outflow tract obstruction, valve embolization and left ventricular perforation were observed in 1.2 percent, 2.0 percent, 3.2 percent, 1.6 percent and 0.4 percent of patients, respectively. Technical success was achieved in 92.3 percent of patients, but the valve-in-ring group had a significantly lower technical success rate compared with the valve-in-valve group (83.3 percent vs. 96.0 percent) due to more frequent second valve implantation (11.1 percent vs. 2.8 percent). Re-intervention (16.7 percent vs. 7.4 percent) and paravalvular leak closure (6.9 percent vs 2.3 percent) were also more common in valve-in-ring patients.

There were no significant differences between the patient groups in 30-day all-cause mortality, stroke, major or extensive bleeding or major vascular complication. However, the valve-in-ring group had more frequent life-threatening or fatal bleeding (8.3 percent vs. 2.3 percent) and stage two or three acute kidney injury (11.1 percent vs. 4.0 percent) compared with the valve-in-valve group, which resulted in a significantly lower procedural success rate in the valve-in-ring group (58.3 percent vs. 79.5 percent).

In an editorial comment accompanying the study, John G. Webb, MD, FACC, et al., examine the last ten years of TMVR for failed surgical implants and conclude that it is "still 'under development.' However, these procedures are poised to become the default therapies when mitral implants fail… Hopefully, new tiered systems of care will allow appropriate access to this new therapy while allowing for sufficient expertise to optimize outcomes."


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