Original Investigation
Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings

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Abstract

Background

Limited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair.

Objectives

This study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]).

Methods

From the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria.

Results

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 with 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, at 92.3% and 85.5%, respectively. However, compared with 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 gradients 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 or higher (19.4% vs. 6.8%; p = 0.003). Furthermore, the 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 with the ViV group (28.7% vs. 12.6%; log-rank test, 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 to 5.43; p = 0.005).

Conclusions

The TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.

Key Words

annuloplasty ring
degenerated bioprostheses
mitral valve
transcatheter valve implantation

Abbreviations and Acronyms

CI
confidence interval
HR
hazard ratio
LVOT
left ventricular outflow tract
MVARC
Mitral Valve Academic Research Consortium
STS
Society of Thoracic Surgeons
TMVR
transcatheter mitral valve replacement
ViR
valve-in-ring
ViV
valve-in-valve

Cited by (0)

The Department of Cardiology at the Leiden University Medical Center received research grants from Edwards Lifesciences, Biotronik, Medtronic, and Boston Scientific. Dr. Whisenant has served as a consultant for Edwards Lifesciences and Boston Scientific. Dr. Bleiziffer has served as a consultant to Medtronic; as a proctor for Medtronic and JenaValve; and has received travel compensation from Edwards Lifesciences, Medtronic, and Johnson & Johnson. Dr. Delgado has received speaking fees from Abbott Vascular. Dr. Barker is on the advisory board of Medtronic and Boston Scientific; and on the speakers bureau of Abbott Vascular. Dr. Sharma has served as a proctor for Edwards Lifesciences. Dr. Masson has served as a consultant for Edwards Lifesciences. Dr. Wijeysundera has received research grants from Edwards Lifesciences and Medtronic. Drs. Blackman and Smith have served as proctors for Medtronic and Boston Scientific. Dr. Taramasso has served as a consultant for St. Jude Medical. Dr. Attizzani has served as a proctor for Edwards Lifesciences and Medtronic; on the speakers bureau for Medtronic and Abbott Vascular; and as a consultant to St. Jude Medical. Dr. Kaneko is a consultant for Edwards Lifesciences. Dr. Nietlispach has served as a consultant for Edwards Lifesciences, St. Jude Medical, Direct Flow Medical, and Medtronic. Dr. Hengstenberg has served as a proctor for Edwards Lifesciences and Symetis; has received travel compensation from Edwards Lifesciences, Medtronic, and Symetis; and has received speaker honoraria from Edwards Lifesciences and Symetis. Dr. Kasel has served as a consultant for and received research support from Edwards Lifesciences. Drs. Prendergast and Redwood have received speaker fees from Edwards Lifesciences, Boston Scientific, and Symetis. Dr. Kar has received research grants and consulting fees from Abbott Vascular and St. Jude Medical. Dr. Maisano has served as a consultant for Edwards Lifesciences, Medtronic, St. Jude Medical, Abbott Vascular, and Veltech; and has received royalties from Edwards Lifesciences. Dr. Windecker has received research grants to the institution from Abbott, Biotronik, Boston Scientific, Edwards Lifesciences, Medtronic, The Medicines Company, and St. Jude Medical; and has received speaker fees from AstraZeneca, Eli Lilly, Abbott, Biotronik, Boston Scientific, Bayer, and Biosensors. Dr. Pilgrim has received speaker fees from Biotronik and Medtronic; and has received travel honoraria from Biotronik and Edwards Lifesciences. Dr. Ensminger has served as a proctor for JenaValve; has received speaker honoraria from Edwards Lifesciences, JenaValve, and Symetis; and has received travel compensation from Edwards Lifesciences, JenaValve, and Symetis. Dr. Wood has received grant support or research contracts from Boston Scientific; and honoraria from Edwards Lifesciences. Dr. Schofer has received travel support from Edwards Lifesciences and Boston Scientific. Dr. Latib has served on the Medtronic advisory board; and has served as a consultant for Direct Flow Medical. Dr. Makkar has received grants from Edwards Lifesciences; and personal fees from St. Jude Medical and Medtronic. All other authors reported that they have no relationship relevant to the contents of this paper to disclose.

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