Outcomes of transcatheter mitral valve replacement for degenerated bioprostheses, failed annuloplasty rings, and mitral annular calcification

Yoon, S.H.; Whisenant, B.K.; Bleiziffer, S.; Delgado, V.; Dhoble, A.; Schofer, N.; ... ; Makkar, R.R. (2019)

Article / Letter to editor

Aims We sought to evaluate the outcomes of transcatheter mitral valve replacement (TMVR) for patients with degenerated bioprostheses [valve-in-valve (ViV)], failed annuloplasty rings [valve-in-ring (ViR)], and severe mitral annular calcification [valve-in-mitral annular calcification (ViMAC)].Methods and results From the TMVR multicentre registry, procedural and clinical outcomes of ViV, ViR, and ViMAC were compared according to Mitral Valve Academic Research Consortium (MVARC) criteria. A total of 521 patients with mean Society of Thoracic Surgeons score of 9.0 +/- 7.0% underwent TMVR (322 patients with ViV, 141 with ViR, and 58 with ViMAC). Trans-septal access and the Sapien valves were used in 39.5% and 90.0%, respectively. Overall technical success was excellent at 87.1%. However, left ventricular outflow tract obstruction occurred more frequently after ViMAC compared with ViR and ViV (39.7% vs. 5.0% vs. 2.2%; P < 0.001), whereas second valve implantation was more frequent in ViR compared with ViMAC and ViV (12.1% vs. 5.2% vs. 2.5%; P < 0.001). Accordingly, technical success rate was higher after ViV compared with ViR and ViMAC (94.4% vs. 80.9% vs. 62.1%; P < 0.001). Compared with ViMAC and ViV groups, ViR group had more frequent post-procedural mitral regurgitation >= moderate (18.4% vs. 13.8% vs. 5.6%; P < 0.001) and subsequent paravalvular leak closure (7.8% vs. 0.0% vs. 2.2%; P = 0.006). All-cause mortality was higher after ViMAC compared with ViR and ViV at 30 days (34.5% vs. 9.9% vs. 6.2%; log-rank P < 0.001) and 1 year (62.8% vs. 30.6% vs. 14.0%; log-rank P < 0.001). On multivariable analysis, patients with failed annuloplasty rings and severe MAC were at increased risk of mortality after TMVR [ViR vs. ViV, hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.27 - 3.12; P 0.003; ViMAC vs. ViV, HR 5.29, 95% CI 3.29 - 8.51; P < 0.001].Conclusion The TMVR provided excellent outcomes for patients with degenerated bioprostheses despite high surgical risk. However, ViR and ViMAC were associated with higher rates of adverse events and mid-term mortality compared with ViV.

• Mitral valve
• Transcatheter valve implantation
• Degenerated bioprostheses
• Annuloplasty ring
• Mitral annular calcification

• All authors: Yoon, S.H.; Whisenant, B.K.; Bleiziffer, S.; Delgado, V.; Dhoble, A.; Schofer, N.; Eschenbach, L.; Bansal, E.; Murdoch, D.J.; Ancona, M.; Schmidt, T.; Yzeiraj, E.; Vincent, F.; Niikura, H.; Kim, W.K.; Asami, M.; Unbehaun, A.; Hirji, S.; Fujita, B.; Silaschi, M.; Tang, G.H.L.; Kuwata, S.; Wong, S.C.; Frangieh, A.H.; Barker, C.M.; Davies, J.E.; Lauten, A.; Deuschl, F.; Nombela-Franco, L.; Rampat, R.; Nicz, P.F.G.; Masson, J.B.; Wijeysundera, H.C.; Sievert, H.; Blackman, D.J.; Gutierrez-Ibanes, E.; Sugiyama, D.; Chakravarty, T.; Hildick-Smith, D.; Brito, F.S. de; Jensen, C.; Jung, C.; Smalling, R.; Arnold, M.; Redwood, S.; Kasel, A.M.; Maisano, F.; Treede, H.; Ensminger, S.M.; Kar, S.; Kaneko, T.; Pilgrim, T.; Sorajja, P.; Belle, E. van; Prendergast, B.D.; Bapat, V.; Modine, T.; Schofer, J.; Frerker, C.; Kempfert, J.; Attizzani, G.F.; Latib, A.; Schaefer, U.; Webb, J.G.; Bax, J.J.; Makkar, R.R.
• Date: 2019-02-01
• Journal: European Heart Journal
• Volume: 40
• Issue: 5
• Pages: 441 - 451
• DOI: doi:10.1093/eurheartj/ehy590