Transcatheter Mitral Valve Replacement for Failed Mitral Bioprostheses

Study Questions:

What are the outcomes of transcatheter mitral valve replacement (TMVR) in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR])?


The investigators compared procedural and clinical outcomes of mitral ViV and ViR from the TMVR multicenter registry, according to Mitral Valve Academic Research Consortium (MVARC) criteria. The TMVR registry is an international, multicenter, observational study that enrolled all consecutive patients with mitral degenerated bioprostheses and failed annuloplasty rings undergoing TMVR. Cumulative rates of death were calculated using the Kaplan-Meier survival analysis, and the log-rank test was used for comparisons across the groups.


A total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8 underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared to 176 patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; p < 0.001). Overall technical and device success rates were acceptable with 92.3% and 85.5%, respectively. However, compared to the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; p = 0.001) due to more frequent second valve implantation (11.1% vs. 2.8%; p = 0.008), and lower device success (76.4% vs. 89.2%; p = 0.009) due to more frequent reintervention (16.7% vs. 7.4%; p = 0.03). Mean mitral valve gradient were similar between groups (6.4 ± 2.3 mm Hg vs. 5.8 ± 2.7 mm Hg; p = 0.17), whereas the ViR group had more frequent post-procedural mitral regurgitation ≥ moderate (19.4% vs. 6.8%; p = 0.003). Furthermore, ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; p = 0.03), acute kidney injury (11.1% vs. 4.0%; p = 0.03), and subsequent lower procedural success (58.3% vs. 79.5%; p = 0.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared to the ViV group (28.7% vs. 12.6%; log-rank p = 0.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio, 2.70; 95% confidence interval, 1.34-5.43; p = 0.005).


The authors concluded that the TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings.


This registry study reports that the procedural and clinical outcomes of TMVR for patients with degenerated mitral bioprostheses and failed annuloplasty rings were acceptable despite high surgical risk with multiple comorbidities. Compared to patients with degenerated mitral bioprostheses, TMVR for patients with failed annuloplasty rings was associated with lower rates of technical, device, and procedural success and the cumulative event rates for all-cause mortality at 1-year follow-up were higher in patients with failed annuloplasty rings compared to those with degenerated mitral bioprostheses. Additional prospective studies with independent adjunction of adverse events and an independent core laboratory are needed to confirm these findings and to assess the optimal duration of anticoagulation treatment after TMVR.

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

Keywords: Acute Kidney Injury, Bioprosthesis, Cardiac Surgical Procedures, Cardiac Valve Annuloplasty, Comorbidity, Heart Valve Diseases, Hemorrhage, Mitral Valve Insufficiency, Outcome Assessment (Health Care), Survival Analysis, Transcatheter Aortic Valve Replacement

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