Transapical aortic valve and mitral valve in ring prosthesis implantation - a new advance in transcatheter procedures

Reoperative Mitral Surgery Versus Transcatheter Mitral Valve Replacement: A Systematic Review

Bioprosthetic mitral structural valve degeneration and failed mitral valve repair (MVr) have traditionally been treated with reoperative mitral valve surgery. Transcatheter mitral valve-in-valve (MVIV) and valve-in-ring (MVIR) replacement are now feasible, but data comparing these approaches are lacking. We sought to compare the outcomes of (1) reoperative mitral valve replacement (redo-MVR) and MVIV for structural valve degeneration, and (2) reoperative mitral valve repair (redo-MVr) or MVR and MVIR for failed MVr. A literature search of PubMed, Embase, and the Cochrane Library was conducted up to July 31, 2020. Thirty-two studies involving 25 832 patients were included. Redo-MVR was required in ≈35% of patients after index surgery at 10 years, with 5% to 15% 30-day mortality. MVIV resulted in >95% procedural success with 30-day and 1-year mortality of 0% to 8% and 11% to 16%, respectively. Recognized complications included left ventricular outflow tract obstruction (0%-6%), valve migration (0%-9%), and residual regurgitation (0%-6%). Comparisons of redo-MVR and MVIV showed no statistically significant differences in mortality (11.3% versus 11.9% at 1 year, P=0.92), albeit higher rates of major bleeding and arrhythmias with redo-MVR. MVIR resulted in 0% to 34% mortality at 1 year, whereas both redo-MVr and MVR for failed repairs were performed with minimal mortality and durable long-term results. MVIV is therefore a viable alternative to redo-MVR for structural valve degeneration, whereas redo-MVr or redo-MVR is preferred for failed MVr given the suboptimal results with MVIR. However, not all patients will be candidates for MVIV/MVIR because anatomical restrictions may preclude transcatheter options from adequately addressing the underlying pathology.

Transcatheter mitral valve implantation for degenerated mitral bioprostheses or failed surgical annuloplasty rings: A systematic review and meta-analysis

BACKGROUND

Transcatheter mitral valve-in-valve (TMVIV) and valve-in-ring (TMVIR) implantation for degenerated mitral bioprostheses and failed annuloplasty rings have recently emerged as treatment options for patients deemed unsuitable for repeat surgery.

METHODS

A systematic literature review was conducted to summarize the data regarding the baseline characteristics and clinical outcomes of patients undergoing TMVIV and TMVIR procedures.

RESULTS

A total of 245 patients (172 patients who underwent TMVIV surgery and 73 patients who underwent TMVIR surgery) were included in the study; 93.5% of patients experienced successful TMVIV or TMVIR implantation. The mortality rates at discharge, 30 days, and 6 months were 5.7%, 8.1%, and 23.4%, respectively. The transapical (TA) access route was used in most procedures (55.2%). The TA and transseptal (TS) access routes resulted in similar outcomes. No significant differences were observed in the short-term outcomes between the patients who developed mitral stenosis versus mitral regurgitation as the mode of failure.

CONCLUSIONS

TMVIV and TMVIR implantation for degenerated mitral bioprostheses and failed annuloplasty rings are safe and effective. Both procedures, via TA or TS access, can result in excellent short-term clinical outcomes in patients with mitral stenosis or regurgitation, but long-term follow-up data are currently lacking to determine the durability of these procedures.

Transseptal Transcatheter Mitral Valve Replacement for Post-Surgical Mitral Failures

Post-surgical deterioration of mitral valve repairs or replacements may present a clinical dilemma due to the high-risk nature of repeat surgery. Recent advances in transcatheter techniques and surgery have enabled the implantation of balloon-expandable valves in the mitral position when surgical rings and valves are present. Valves may be implanted either via transseptal or transapical access, with a reported success rate between 88-100 %.

A systematic review of reported cases of combined transcatheter aortic and mitral valve interventions

OBJECTIVES

To summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI).

BACKGROUND

CTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve-in-valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve-in-valve/valve-in-ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high-surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described.

METHODS

We performed a systematic review of all the published articles from PUBMED and EMBASE.

RESULTS

A total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6-365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post-procedure was rare.

CONCLUSIONS

CTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future.

New expandable mitral annuloplasty ring facilitates transcatheter mitral valve implantation: proof of concept

AIMS

Transcatheter mitral valve-in-ring (TMVIR) implantation with transcatheter heart valve (THV) prostheses can be performed in patients with recurrent mitral regurgitation (MR) following annuloplasty. However, an oval configuration and sometimes the rigidity of surgical rings can often lead to suboptimal THV expansion, resulting in considerable paravalvular or central leakage. Therefore, our aim was to develop an annuloplasty ring that fully adjusts to THV implantation.

METHODS AND RESULTS

A three-dimensional annuloplasty ring was separated into four pieces at defined locations, the sections were reconnected with heat-shrinkable tubing and rearranged into the original shape. A non-tear stainless steel circular cord of defined length was inserted into the ring's sewing cuff to serve as a limiting structure for THV expansion. We implanted this ring in the mitral position into an isolated pig heart, deployed a THV into the ring, and investigated its function. Fluoroscopy showed that, upon THV deployment, the four breaking points of the ring separated as expected, and the ring expanded in a circular fashion to full expansion of the limiting cord. It securely anchored the THV to the ring, leaving no paravalvular gaps.

CONCLUSIONS

We developed an expandable mitral ring to which the THV attached without leakage. This may impact on the future design of annuloplasty rings. Further studies should evaluate the safety of increasing the perimeter of a mitral ring and its durability.