5-Year Experience With Transcatheter Transapical Mitral Valve-in-Valve Implantation for Bioprosthetic Valve Dysfunction

Study Questions:

What are the clinical outcomes of patients undergoing transcatheter valve-in-valve (TVIV) implantation for degenerated mitral valve bioprostheses?

Methods:

This cases series describes procedural success and outcomes in 23 consecutive patients with symptomatic mitral valve bioprostheses dysfunction who were treated with TVIV implantation using an apical approach with an Edwards Sapien valve. Patients had symptomatic degeneration of the mitral valve bioprosthesis (stenosis in six cases, regurgitation in nine cases, and mixed in eight cases), and were deemed not to be surgical candidates for re-do surgical mitral valve replacement. No patients had significant paravalvular regurgitation.

Results:

Mean age was 81 ± 1 year, and 61% were female. All 23 procedures were successful, with no cases of malpositioning or embolization of the valve. A stroke occurred in one patient (4%), two patients had acute renal injury (9%), and six patients (26%) had major bleeding. Following the procedure, 10 patients had mild mitral regurgitation, and 13 had no regurgitation, with no patients having moderate or severe regurgitation; mean transvalvular gradient decreased from 11 ± 5 to 7 ± 2 mm Hg (p = 0.01). All patients were alive at 30 days. At a median follow-up of 2.1 years (interquartile range, 1.0-3.6 years), all-cause mortality was observed in two patients (10%), and there was one case (4%) of valve migration and severe regurgitation requiring valve re-implantation. No patient had moderate or severe regurgitation on latest follow-up. Clinical improvement to New York Heart Association functional class I or II was observed in 96% of patients.

Conclusions:

In patients deemed at prohibitive surgical risk, transapical TVIV implantations for degenerated mitral valve bioprostheses were associated with a significant improvement in valve hemodynamics and patient symptoms, with low rates of morbidity and mortality.

Perspective:

This study demonstrates a potential new role for transcatheter valve implantation in patients with degenerated mitral valve bioprostheses and at excess risk for repeat surgical valve replacement. In the past, these patients may have had no alternatives for valve replacement, and this procedure may represent an important option in symptomatic patients. While this approach utilizes a transapical approach, which is more invasive than arterial approaches, the low rate of adverse events and improvement in patient symptoms and hemodynamics is reassuring. Nevertheless, it must be acknowledged that this is experience from a single site with a high level of expertise in transcatheter aortic valve procedures, and it is probable that procedural success and outcomes may be less robust at less experienced centers, particularly as optimal patient selection, valve sizing, and procedural techniques are still not established.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Heart Valve Prosthesis, Stroke, Follow-Up Studies, Mitral Valve Insufficiency, Acute Kidney Injury, Constriction, Pathologic, Heart Valve Prosthesis Implantation, New York, Angioplasty, Balloon, Coronary, Hemodynamics, Patient Selection, Bioprosthesis, Heart Valve Diseases


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