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Surgical vs. Transcatheter MV Replacement for Failed Mitral Prostheses
Quick Takes
- Among U.S. patients aged ≥65 years with failed mitral prostheses who underwent redo surgical or transcatheter mitral valve replacement, transcatheter valve replacement had more favorable outcomes in the first 6 months but less favorable longer-term outcomes.
- In cases of redo surgical mitral valve replacement, with increasing center procedural volume, there was a graded decline in rates of in-hospital death and mid-term adverse outcomes.
Study Questions:
In patients with failed mitral valve prostheses, what are the clinical outcomes of redo surgical mitral valve replacement (SMVR) versus transcatheter mitral valve replacement (TMVR), and how does hospital case volume relate to outcomes?
Methods:
From the Medicare inpatient fee-for-service 100% sample claims database, U.S. patients aged ≥65 years who underwent redo SMVR or TMVR for failed mitral prostheses from 2016–2020 were included. The primary endpoint was mid-term (up to 3 years) major adverse cardiovascular events (MACE), a composite of all-cause death, heart failure hospitalization, stroke, and reintervention. In comparing outcomes between redo SMVR and TMVR, a propensity-score matching approach (1:1 ratio) was used to account for confounders. Centers were divided into quartiles based on procedural volumes for outcome comparisons.
Results:
The study population was comprised of 4,293 patients, of whom 2,732 (64%) underwent redo SMVR and 1,561 (36%) underwent TMVR. Among SMVR patients, 53.4% had a concomitant procedure (aortic valve replacement in 26.9%, tricuspid valve surgery in 25.9%, and coronary artery bypass grafting in 15.6%). The median follow-up period was 18 months. A trend toward increasing TMVR volume occurred over the study period.
Multivariable logistic regression analysis identified several independent predictors for undergoing TMVR rather than SMVR: older age, female sex, heart failure, chronic obstructive pulmonary disease, liver disease, dementia, and severe comorbidity burden (Charlson Comorbidity Index ≥5). TMVR patients had shorter length of stay (median 3 vs. 11 days, p < 0.001) and significantly lower rates of in-hospital complications such as acute kidney injury, cardiogenic shock, and permanent pacemaker implantation, as well as all-cause death (10.9% vs. 5.1%, p < 0.001).
Kaplan-Meier estimates of MACE at 3 years were 44% in both cohorts, but TMVR was associated with lower MACE risk in the initial 6 months (adjusted hazard ratio [aHR], 0.75; 95% confidence interval [CI], 0.63-0.88; p < 0.001) and a higher risk beyond 6 months (aHR, 1.28; 95% CI, 1.04-1.58; p = 0.02). Risk of all-cause death was lower in the short-term with TMVR (aHR, 0.71; 95% CI, 0.59-0.86; p < 0.001) but not significantly different beyond 6 months.
A total of 659 institutions were included, with 289 performing both redo SMVR and TMVR. A majority of centers (86%) performed fewer than 10 cases during the study period. In cases of redo SMVR, with increasing center volume, there was a graded decline in rates of in-hospital death (7.9% in quartile 4 vs. 16.1% in quartile 1; p < 0.001), mid-term death (23.4% vs. 31.7%; aHR, 0.67; p < 0.001 for trend), and mid-term MACE (31.3% vs. 37.2%; aHR, 0.78; p = 0.003 for trend). No such trend was seen for TMVR.
Conclusions:
Among patients ≥65 years of age undergoing redo SMVR or TMVR for failed mitral prostheses, TMVR is associated with lower risk of short-term adverse events but higher risk thereafter. For redo SMVR, centers with higher procedural volumes have more favorable outcomes.
Perspective:
These findings suggest that redo SMVR is best performed in higher-volume centers. All patients with failed prosthetic valves should be treated with a heart team approach when possible, carefully considering the technical feasibility and clinical risks associated with open and transcatheter-based interventions. As this was an observational study, residual confounding may have influenced the results; the higher comorbidity burden in the TMVR cohort likely had a negative impact on longer-term outcomes. Other limitations of this study include lack of data on pre- and post-procedural valve hemodynamics, as well as concomitant tricuspid regurgitation, which negatively impacts long-term outcomes of mitral valve interventions.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Cardiac Surgical Procedures, Heart Valve Diseases
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