Expanding treatment horizons: transcatheter mitral valve-in-valve replacement in bridging to heart transplant.

Transcatheter mitral valve (MV) replacement is an option in complex MV disease with potentially more predictable treatment outcomes and less invasiveness that increases the treatment spectrum to high-risk or non-surgical patients. We present an interesting case of failed MV bioprosthesis who presented with progressively worsening heart failure for heart transplant evaluation, but was successfully managed with transcatheter mitral valve-in-valve replacement (TMViVR). This case illustrates the pivotal role of TMViVR utilization in addressing complex cardiac scenarios, particularly when re-operative surgical MV replacement poses a high risk and also bridging the gap between the present and future heart transplantation preparations by paving the way for a well-prepared patient in the subsequent phase. The lifetime disease management and patient-centric approach with meticulous risk assessment reinforces the importance of shared decision-making in complex cases.

Transcatheter mitral valve-in-valve for pregnancy with anti-phospholipid syndrome: a case report.

BACKGROUND: Perioperative management and cardiac surgery in pregnant women with anti-phospholipid syndrome combined with heart valve disease have been rarely reported. CASE PRESENTATION: We describe a case of transcatheter mitral valve-in-valve replacement in a pregnant woman with bioprosthetic valve failure and anti-phospholipid syndrome at 18 weeks' gestation. The patient underwent a cesarean section delivery at 34 weeks of gestation, resulting in the birth of a healthy baby. CONCLUSIONS: Transapical mitral valve-in-valve surgery resulted in safe maternal and infant outcomes in a pregnant woman with anti-phospholipid syndrome combined with mitral bioprosthetic valve failure. The success of this procedure underscored the importance of multidisciplinary teamwork.

Cardiac Structural and Functional Remodeling After Transcatheter Mitral Valve in Valve Implantation: Early Changes and Prognostic Significance.

Background: Transcatheter mitral valve-in-valve (MViV) replacement has emerged as an alternative to redo mitral valve (MV) surgery for the management of failed bioprosthetic MVs. The degree of cardiac remodeling assessed by echocardiography has been shown to have prognostic implications in degenerative mitral regurgitation patients undergoing MV surgery. The impact of transcatheter MViV in patients with degenerative bioprosthetic MV failure on cardiac remodeling and its associated prognosis remains undescribed. Objectives: The aim of this study is to describe the early anatomic and functional changes of the left-sided chambers and right ventricle by echocardiography posttranscatheter MViV intervention and their impact on mortality outcomes. Additionally, we sought to analyze the outcome of heart failure in bioprosthetic MV failure patients undergoing transcatheter MViV replacement. Methods: We analyzed consecutive patients undergoing MViV intervention for symptomatic bioprosthetic MV failure. Echocardiograms before intervention and within 100 days postintervention were analyzed. A chart review was performed to obtain baseline characteristics, follow-up visits, 30-day heart failure and 1-year all-cause mortality outcomes. Results: A total of 62 patients (mean age 69 ± 13 years, 61% male) were included in the study. Most patients were undergoing MViV intervention for prosthetic mitral stenosis n = 48 (77.4%) and the rest for mitral regurgitation or mixed disease. Compared with baseline, significant reductions were observed in median left atrial volume (LAV; 103 [81-129] ml vs. 95.2 [74.5-117.5] ml, p < 0.01) and mean (SD) left atrial conduit strain (9.1% ± 5.2% vs. 10.8% ± 4.8%, p = 0.039) within 100 days postintervention. Early reduction in right ventricular free wall global longitudinal strain and fractional area change also occurred postintervention. No significant change in left ventricular chamber dimensions or ejection fraction was observed. During the 1-year follow up period, 5 (8%) patients died. While baseline LAV was not associated with 1-year all-cause mortality (OR 0.98 CI 0.95-1.01; p = 0.27), a change in LAV in the follow up period was associated with all-cause mortality at 1 year (OR 1.06 CI 1.01-1.12; p = 0.023). At 30 days postintervention, 65% of patients had an improvement in their New York Heart Association functional class. Conclusion: In this retrospective study of patients undergoing transcatheter MViV intervention for failed bioprosthetic MVs, early reverse remodeling of the left atrium occurs within 100 days postintervention and reduction in LAV is associated with reduced all-cause mortality at 1 year. In addition, there is significant improvement in heart failure symptoms at 30 days following intervention but further investigation into the longitudinal remodeling changes and long-term outcomes is needed.

Clinical Outcomes Following Transcatheter Mitral Valve-in-Valve Replacement Using a Meril Myval Transcatheter Heart Valve.

AIM: Transcatheter mitral valve-in-valve (TMViV) replacement for degenerated surgically implanted bioprosthetic valves has been described by both transseptal and transapical approaches. The balloon-expandable Myval transcatheter valve (Meril Life Sciences, Vapi, India) is commonly used for transcatheter valve-in-valve procedures in India. This study aimed to report in-hospital, 30-day, and 1-year outcomes of Myval patients who underwent TMViV in a single tertiary care centre in India. METHODS: Symptomatic patients with surgical bioprosthetic mitral valve failure with New York Heart Association (NYHA) class III-IV symptoms, despite optimal medical therapy and high or very high risk for redo surgery, were assigned to TMViV following heart team discussions. Data were retrospectively collected and outcomes assessed. RESULTS: Twenty patients were treated, with mean age 64.4 years, 60% were female, and mean Society of Thoracic Surgeons (STS) predicted risk of operative mortality score was 8.1. The failure mechanism was combined stenosis and regurgitation in 60% of patients. Technical success was achieved in 100% of patients. The mean postprocedure and 30-day gradients were 4.6±2.7 and 6.3±2.1, respectively. None of them had significant valvular or paravalvular leaks or left ventricular outflow tract obstruction. All-cause mortality at 1 year was 10%, and all survivors were in New York Heart Association (NYHA) class I or II. CONCLUSION: TMViV replacement with a Meril Myval can be safely performed with high technical success, and low 30-day and 1-year mortality.

Redo Mitral Valve Replacement After Valve-in-Valve Transcatheter Mitral Valve Replacement.

The rising preference for percutaneous mitral valve-in-valve replacement (ViV TMVR) over redo surgical mitral valve replacement (MVR) is primarily due to its reduced bleeding risk. This report details a bloodless redo MVR performed for mitral stenosis post-ViV TMVR. We present detailed intraoperative findings, including images of the extracted bioprosthetic valves and cardiac anatomy, providing valuable insights into the surgical complexities encountered. The case underscores the importance of meticulous planning and execution in redo MVR, especially in patients with a history of multiple valve interventions. Additionally, this report discusses the potential complications associated with ViV TMVR, contributing to the evolving understanding of this procedure's long-term outcomes. Our findings highlight the need for careful consideration of patient-specific factors and the inherent risks of redo valve surgeries, aiming to improve patient outcomes in complex cardiac cases.

Premature Bioprosthetic Mitral Valve Dysfunction Due to Flail Leaflet Treated With Transcatheter Mitral Valve Replacement; a Case Report.

Early bioprosthetic mitral valve failure is uncommon, but cases can present with symptomatic heart failure and require careful attention and evaluation. Transcatheter valve replacement is a minimally invasive treatment for mitral valve dysfunction that can have a considerable impact, particularly for those who are at high surgical risk or have a history of bioprosthetic valve failure. We present a rare case of significant mitral regurgitation due to the unexpected premature failure of a bioprosthetic valve that was implanted three years prior. This patient was treated with transcatheter mitral valve replacement with the implantation of an Edwards SAPIEN Ultra (Edwards Lifesciences) valve.

Transcatheter mitral valve-in-valve: treatment of rheumatic heart disease in young patients.

BACKGROUND: Rheumatic heart disease (RHD) in young people presents a complex management problem. In Australia a significant proportion of those affected are Aboriginal and Torres Strait Islanders. Transcatheter mitral valve-in-valve (TMViV) replacement has emerged as an alternative to redo surgery in high-risk patients with degenerated mitral bioprostheses. The aim of this study is to review outcomes of TMViV replacement in young patients with RHD. METHODS: A single-centre, retrospective review of prospectively collected data on patients undergoing TMViV from December 2017 to June 2021. Primary outcome was major adverse cardiovascular events. Secondary outcome was post-operative trans-thoracic echocardiogram (TTE) results. RESULTS: There were seven patients with a mean age of 33 years and predominantly female (n = 5). Pre-operative comorbidities included diabetes (29%), chronic obstructive pulmonary disease (43%), left ventricular dysfunction (43%) and current smoking status (80%). Post-operative median length of hospital stay was 4 days with no post-operative renal failure, stroke, return to theatre, valve embolization or in hospital mortality. Post-operative TTE showed either nil or trivial central mitral regurgitation, no paravalvular leak and a median gradient of 5 mmHg (IQR 4.5, 7) across the new bioprosthesis; sustained at median follow-up of 22 months. CONCLUSION: Current literature of TMViV replacement is focused on an older population with concurrent comorbidities. This study provides a unique insight into TMViV replacement in a young cohort of patients with complex social and geographical factors which sometimes prohibits the use of a mechanical valve. The prevalence of RHD remains high for Aboriginal and Torres Strait Islanders, planning for future repeat valve operations should be considered from the outset. We consider TMViV as a part of a staged procedural journey for young patients with RHD.

Transcatheter mitral valve implantation versus conventional redo surgery for degenerated mitral valve prostheses and rings in a multicenter registry.

OBJECTIVES: Degeneration of mitral prostheses/rings may be treated by redo surgery, and, recently, by transcatheter valve-in-valve/ring implantation. This multicenter registry presents results of transcatheter valve-in-valve and repeat surgery for prostheses/rings degeneration. METHODS: Data provided by 10 German heart centers underwent propensity score-matched retrospective analysis. The primary endpoint was 30-day/midterm mortality. Perioperative outcome was assessed according to the Mitral Valve Academic Research Consortium criteria. Further, the influence of moderate or greater tricuspid regurgitation (TR) on 30-day/midterm mortality was analyzed. RESULTS: Between 2014 and 2019, 273 patients (79 transcatheter mitral valve-in-valve [TM-ViV] and 194 redo mitral valve replacement [Re-MVR]) underwent repeat procedure for mitral prosthesis/ring degeneration. Propensity score matching distinguished 79 patient pairs. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II-predicted risk was 15.7 ± 13.7% in the TM-ViV group and 15.0% ± 12.7% in the Re-MVR group (P = .5336). TM-ViV patients were older (74.73 vs 72.2 years; P = .0030) and had higher incidence of atrial fibrillation (54 vs 40 patients; P = .0233). Severe TR incidence was similar (17.95% in TM-ViV vs 14.10%; P = .1741). Sixty-eight TM-ViV patients previously underwent mitral valve replacement, whereas 41 Re-MVR patients underwent valve repair (P < .0001). Stenosis was the leading degeneration mechanism in 42 TM-ViV versus 22 Re-MVR patients (P < .0005). The 30-day/midterm mortality did not differ between groups. Moderate or greater TR was a predictor of total (odds ratio [OR], 4.36; P = .0011), 30-day (OR, 3.76; P = .0180), and midterm mortality (OR, 4.30; P = .0378), irrespective of group. CONCLUSIONS: In both groups, observed mortality was less than predicted. Redo surgery enabled treatment of concomitant conditions, such as atrial fibrillation or TR. TR was shown to be a predictor of total, 30-day, and midterm mortality in both groups.

Late Balloon Valvuloplasty for Transcatheter Heart Valve Dysfunction.

BACKGROUND: Transcatheter heart valve (THV) dysfunction with an elevated gradient or paravalvular leak (PVL) may be documented late after THV implantation. Medical management, paravalvular plugs, redo THV replacement, or surgical valve replacement may be considered. However, late balloon dilatation is rarely utilized because of concerns about safety or lack of efficacy. OBJECTIVES: We aimed to evaluate the safety and efficacy of late dilatation in the management of THV dysfunction. METHODS: All patients who underwent late dilatation for symptomatic THV dysfunction at 2 institutions between 2016 and 2021 were identified. Baseline, procedural characteristics, and clinical and echocardiographic outcomes were documented. THV frame expansion was assessed by multislice computed tomography before and after late dilatation. RESULTS: Late dilatation was performed in 30 patients a median of 4.6 months (IQR: 2.3-11.0 months) after THV implantation in the aortic (n = 25; 83.3%), mitral (n = 2; 6.7%), tricuspid (n = 2; 6.7%) and pulmonary (n = 1; 3.3%) position. THV underexpansion was documented at baseline, and frame expansion substantially improved after late dilatation. The mean transvalvular gradient fell in all patients. For aortic THVs specifically, mean transaortic gradient fell from 25.4 ± 13.9 mm Hg to 10.8 ± 4.1 mm Hg; P < 0.001. PVL was reduced to ≤mild in all 11 patients with a previous >mild PVL. Embolic events, stroke, annular injury, and bioprosthetic leaflet injury were not observed. Symptomatic benefit was durable at 19.6 months (IQR: 14.8-36.1 months) follow-up. CONCLUSIONS: Balloon dilatation late after THV implantation appears feasible and safe in appropriately selected patients and may result in THV frame expansion resulting in improvements in hemodynamic performance and PVL.

Transapical transcatheter mitral valve implantation in patients with degenerated mitral bioprostheses or failed ring annuloplasty.

BACKGROUND: We sought to evaluate the outcomes of transapical transcatheter mitral valve replacement in patients with degenerated mitral bioprostheses or failed mitral ring annuloplasty and high surgical risk for redo mitral valve procedure. METHODS: Between August 2012 and December 2020, 41 consecutive high-risk patients underwent transcatheter mitral 'valve-in-valve' (TM-ViV, n=25) or 'valve-in-ring' (TM-ViR, n=16) implantation at our institution. All procedures were performed in a hybrid operating theater using the SAPIEN XT/3™ or the DIRECT FLOW MEDICAL™ prostheses. Data was collected prospectively according to MVARC criteria. RESULTS: The logistic EuroSCORE-I was 42.3%±20.5% (mean ± SD), the Society of Thoracic Surgeons (STS) score was 11.9%±10.8%, and the STS/ACC-score was 7.6%±4.2%. Transcatheter mitral valve implantations were successful in all patients (100%). Early echocardiographic examinations showed no obstruction of the left ventricular outflow tract (LVOT), no paravalvular leakage, and only trace transvalvular leakage in eight patients. There was no operative mortality; thirty-day mortality was 9.8%. Survival was 72% at one year and 63% at three years. At two-year follow-up, transvalvular mean pressure gradients were 4.6±1.4 mmHg. CONCLUSIONS: Transapical transcatheter mitral valve-in-valve or valve-in-ring implantation represents a true minimally invasive alternative to surgical redo procedures, especially in high-risk patients with failed bioprosthetic mitral valves or annuloplasty and favorable anatomy.

Trends in redo mitral procedure for treating mitral bioprostheses failure: a single center's experience.

BACKGROUND: Transcatheter mitral valve-in-valve implantation (TM-VIV) has emerged as a viable and attractive alternative to surgical mitral valve replacement (SMVR). This study aimed to review a single-center experience with redo mitral procedure for mitral bioprostheses failure over an 8-year period. In addition, it compared procedural safety and early outcomes of various approaches. METHODS: Between January 2013 and January 2021, 79 consecutive patients who underwent redo procedure for mitral bioprostheses failure in our institution were retrospectively reviewed. SMVR and transapical TM-VIV were performed in 54 and 25 patients, respectively. In the SMVR group, 12 patients underwent totally thoracoscopic redo mitral valve replacement (MVR). RESULTS: The annual volume of procedures grew continuously during the study period, with the use of totally thoracoscopic redo MVR increasing from 0% in 2012 to 20% in 2019. In 2020, 84.2% of total procedures were performed via the transcatheter approach. Patients in the TM-VIV group were significantly older and had higher scores on the European System for Cardiac Operative Risk Evaluation II (EuroScore II) and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) (P<0.01). The in-hospital mortality for the SMVR group and TM-VIV group was 3.7% (2 patients) and 0, respectively. Compared to the SMVR group, TM-VIV was associated with shorter ventilation time, intensive care unit stay, and postoperative in-hospital stay, and there was less need for blood transfusion. In the subgroup analysis, no significant difference was detected among most perioperative outcomes between the totally thoracoscopy approach group and the TM-VIV group. CONCLUSIONS: There is an increasing number of patients demanding surgical treatments for mitral bioprostheses failure. TM-VIV is playing a significant role due to its scope of application and excellent outcomes.

Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve in Valve From the National Inpatient Sample.

Background Redo mitral valve surgery is required in up to one-third of patients and is associated with significant mortality and morbidity. Valve-in-valve transcatheter mitral valve replacement (ViV TMVR) is less invasive and could be considered in those at prohibitive surgical risk. Studies on comparative outcomes of ViV TMVR and redo surgical mitral valve replacement (SMVR) remain limited. Our study aimed to investigate the real-world outcomes of the above procedures using the National Inpatient Sample database. Methods and Results We analyzed National Inpatient Sample data using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) from September 2015 to December 2018. A total of 495 and 2250 patients underwent redo ViV TMVR and SMVR, respectively. The patients who underwent ViV TMVR were older (77 versus 68 years, P<0.01). Adjusted mortality was higher in the redo SMVR group compared with the ViV TMVR group (7.6% versus <2.8%, P<0.01). Perioperative complications were higher among patients undergoing redo SMVR including blood transfusions (38% versus 7.6%, P<0.01) and acute kidney injury (36.7% versus 13.9%, P<0.01). Cost of care was higher (USD$57 172 versus USD$52 579, P<0.01), length of stay was longer (10 versus 3 days, P<0.01), and discharge to home was lower (20.3% versus 64.6%, P<0.01) in the SMVR group compared with the ViV TMVR group. Conclusions ViV TMVR is associated with lower mortality, periprocedural morbidity, and resource use compared with patients undergoing redo SMVR. ViV TMVR may be a viable option for some patients with mitral prosthesis dysfunction. Studies evaluating long-term outcomes and durability of ViV TMVR are needed. A patient-centered approach by the heart team, local institutional expertise, and careful preprocedure planning can help decision-making about the choice of intervention for the individual patient.

Real-time intraoperative co-registration of transesophageal echocardiography with fluoroscopy facilitates transcatheter mitral valve-in-valve implantation in cases of invisible degenerated bioprosthetic valves.

OBJECTIVES: Transcatheter mitral valve-in-valve (TMViV) implantation is an alternative treatment to surgery for high-risk patients with degenerated bioprosthetic mitral valves. Some types of bioprostheses are fluoroscopically translucent, resulting in an 'invisible' target deployment area. In this study, we describe the feasibility and outcomes of this procedure using intraoperative fusion of transoesophageal echocardiography (TEE) and live fluoroscopy to facilitate valve deployment in cases of invisible bioprosthetic valves. METHODS: We reviewed all TMViV implantations at our centre from July 2014 to July 2019. Patient, procedure and outcome details were compared between those with a visible bioprosthesis (N = 22) to those with an invisible one (N = 12). Intra-operative TEE and live Fluoroscopy co-registration were used for real-time guidance for all invisible targets. RESULTS: All valve implantations were completed successfully in both groups without cardiovascular injury, valve migration or left ventricular outflow-tract obstruction. Technical success was 100% in both groups. One-year survival was 83% [95% confidence interval (CI) 70-96] for the entire cohort, with 79% (95% CI 63-100) survival for the visible group and 92% (95% CI 77-100) for the invisible group. Probability of 1-year survival free from mitral valve reintervention, significant valve dysfunction, stroke or myocardial infraction was 78% (95% CI 63-93) for all patients whereby the probability was 72% (95% CI 54-97) in the visible group and 80% (95% CI 59-100) for the invisible group. CONCLUSIONS: The use of intraoperative TEE and live fluoroscopy image fusion facilitates accurate TMViV among patients with a fluoroscopically invisible target-landing zone.

Triple Valve Replacement in a Patient with Severe Combined Aortic and Mitral Stenosis.

With recent advancements and evidence in favor of transcatheter approach for valve replacements including valve-in-valve procedures, it has become a favorable choice particularly in critically ill patients. Additionally, transcatheter mitral valve-in-valve replacement (TMViVR) is emerging as a less invasive substitute for patients with early dysfunctional bioprosthetic valve. We describe the clinical course of a 52-year-old male whose initial presentation to the hospital for dyspnea on exertion secondary to combined severe aortic and mitral stenosis got complicated requiring three valvular replacement procedures with favorable outcomes.

Same-Day Discharge After Transcatheter Native Aortic and Mitral Valve-in-Valve Replacement.

Transcatheter aortic valve replacement has become the gold standard of care in the management of patients with severe aortic stenosis and transcatheter mitral valve-in-valve replacement seems to be an attractive alternative to redo surgery. We report the first case of concomitant transcatheter aortic valve replacement/transcatheter mitral valve-in-valve replacement that was performed under conscious sedation who was subsequently discharged the same day. (Level of Difficulty: Advanced.).

Optimal Imaging Guidance During Transcatheter Mitral Valve-in-Valve Replacement in Bioprostheses With Radiolucent Sewing Rings.

Transcatheter mitral valve-in-valve replacement (TMVR) offers a less invasive strategy for managing bioprosthetic mitral valve dysfunction. TMVR positioning is challenging in the setting of a radiolucent bioprosthetic sewing ring. We present 2 cases demonstrating the roles of fluoroscopy and echocardiography in guiding TMVR placement within bioprostheses with radiolucent sewing rings. (Level of Difficulty: Intermediate.).

Transcatheter mitral valve-in-valve implantation: reports of the first 50 cases from a Latin American Centre.

OBJECTIVES: Our goal was to analyse the initial results of the first 50 transapical transcatheter mitral valve-in-valve procedures performed in a single Latin American centre. METHODS: A prospective, single centre, database analysis was conducted to evaluate immediate, 30-day and 1-year postoperative results of 50 consecutive patients who had a transcatheter mitral valve-in-valve procedure from May 2015 to June 2018. All patients were operated on in a hybrid operating room and received a balloon-expandable valve via the transapical approach. Preoperative and postoperative characteristics were analysed and compared between the first 25 and the second 25 patients to evaluate the impact of the learning curve. Twenty patients had a follow-up examination at 1 year. RESULTS: There was a 98% device success rate. The patients had a mean age of 64.8 years; 72% were women; 80% were in New York Heart Association functional class ≥III preoperatively; and 36% of the procedures were urgent. The mean Society of Thoracic Surgeons scores and EuroSCORE II were 8.3% and 12.4%, respectively. Patients had a median of 2 previous operations; valve durability was 12.1 years; and 64% mitral valve disease of rheumatic fever aetiology. Echocardiography showed decreases in the maximum and mean mitral gradients from 23.5 to 14.6 and 11.5 to 6.4 mmHg postoperatively; the overall mean hospitalization period was 15 days. The overall mortality rate at 30 days was 14%, with 1 intraprocedural death. Further subanalyses between the first and the second half of the cases showed a drop in the mortality rate from 20% to 8% (P < 0.01). CONCLUSION: The transcatheter mitral valve-in-valve procedure was shown to be a safe and effective procedure to treat bioprosthetic dysfunction, with potential benefits in patients with rheumatic disease.