Balloon- and Mechanical-Expandable Transcatheter Heart Valves for Mitral Valve-in-Valve and Valve-in-Ring Procedures

Objectives: Valve-in-valve (ViV) or valve-in-ring (ViR) procedures using transcatheter heart valves (THV) in cases of failing mitral valve bioprostheses or rings are established as therapeutic alternatives to redo surgery in high risk patients. We herein report our single center experience in patients undergoing mitral ViV or ViR procedures with balloon (BE)- or mechanical expanding (ME) THV.

Methods: From December 2009 to May 2018, thirty-seven consecutive patients received ViV or ViR procedures for failed mitral valve replacement in 67.6% (25/37) or repair in 32.4% (12/37). Utilized THV types were 27 (72.9%) BE Sapien/SapienXT/Sapien3 and 10 (27.1%) ME Lotus THV. Data were retrospectively analyzed according to Mitral Valve Academic Research Consortium (M-VARC) criteria.

Results: 59.5% of the study population were female, mean age was 70.6 ± 7.4 years and mean logEuroSCORE I was 24.9 ± 15.4%. Indication for treatment was mitral regurgitation in 70.3% (26/37) (BE17/27, 63.0%, ME.9/10, 90.0%; p = 0.2) and mitral stenosis in 29.7% (11/37) (BE10/27, 37.0%v, ME1/10, 10.0%, p = 0.2). Access was transapical in 78.4% (29/37) and transseptal in 21.6% (8/37). Analysis according to M-VARC criteria revealed 30-day mortality of 8.1% (3/37) and a device success rate of 63.6% (21/37) due to one thoracotomy for bleeding, one acute kidney injury, one surgical re-do, two paravalvular leakage 3II, and 11 mean transvalvular gradients of 35 mm Hg. Procedural success was 44.9% (17/37) due to 14 patients with absence of device success, two acute kidney injuries, and one life-threatening bleeding. Transvalvular peak/mean gradients in discharge transthoracic echocardiography were 16.0 ± 4.0/6.6 ± 1.8 mm Hg. There was no significant difference between ViV and ViR in terms of transvalvular peak/mean gradients (15.0 ± 5.6 vs. 17.7 ± 3.3, p = 0.126; 6.5 ± 4.2 vs. 7.6 ± 2.5, p = 0.40). BE and ME groups presented comparable periprocedural data with differences in ViV and ViR patterns (BE ViV 22/27, 81.5% vs. ME 4/10, 40.0%; p = 0.01; BE ViR 5/27, 18.5% vs. ME 6/10, 60.0%; p = 0.01).

Conclusions: ViV and ViR procedures for failed mitral valve replacement and repair show acceptable clinical and hemodynamic results in high-risk patients. An interdisciplinary heart team is mandatory for planning and performance of these complex procedures to guarantee optimal patient safety.