Transvenous Transseptal Mitral Valve Implantation

Study Questions:

What are the feasibility, safety, and intermediate-term outcomes in patients undergoing percutaneous transvenous transcatheter mitral valve implantation in failed bioprosthesis, ring annuloplasty, and calcific mitral stenosis?

Methods:

This is a case series on the off-label use of transcatheter aortic valves for failed surgical mitral bioprosthetic valves or annuloplasty rings and mitral annular calcification (MAC). Percutaneous transfemoral antegrade transseptal implantation of Edwards SAPIEN prosthesis (Edwards Lifesciences, Irvine, CA) was performed in 48 patients with degenerated mitral bioprosthesis (n = 33), previous ring annuloplasty (n = 9), and severe MAC (n = 6). Paired t-tests and Wilcoxon signed rank tests compared pre- and postprocedure variables within patients.

Results:

The mean Society of Thoracic Surgeons risk score was 13.2 ± 7.4% with a mean age of 76 ± 11 years. Acute procedural success was achieved in 42 of 48 patients (88%) in the overall group and 31 of 33 (94%) in the failed bioprosthetic mitral valve group, and success rate of 11 of 15 (73%) in patients with failed annuloplasty rings and MAC. After successful procedure, no patients had > mild residual mitral prosthetic or periprosthetic regurgitation; mean transvalvular gradients were 6 ± 2.5 mm Hg. Thirty-day survival free of death and cardiovascular surgery was 85% in the overall group and 91% in the failed bioprosthetic mitral valve subgroup.

Conclusions:

The authors concluded that transfemoral percutaneous transvenous mitral valve implantation in high-risk patients with degenerated bioprosthesis is safe, effective, and associated with rapid improvement in hemodynamics, short length of stays, and improved functional status.

Perspective:

This case series reports that transvenous transseptal mitral valve implantation with the SAPIEN transcatheter valve is technically feasible and has a high success rate in the setting of a failed mitral bioprosthesis, but transseptal valve-in-valve implantation for failed rings or annular calcification is more challenging. The data presented also suggest that complications are frequent following the implantation of transcatheter aortic valves for failed surgical mitral bioprosthetic valves or annuloplasty rings and MAC. Patient selection appears to be the key to minimizing these complications. Finally, while percutaneous mitral valve implantation shows promise, there are significant challenges that require additional study, and there is a need for dedicated percutaneous mitral devices.

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

Keywords: Aortic Valve, Bioprosthesis, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Hemodynamics, Length of Stay, Mitral Valve Annuloplasty, Mitral Valve Stenosis, Outcome Assessment (Health Care), Transcatheter Aortic Valve Replacement


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