Adult: Mitral Valve
Transcatheter mitral valve implantation versus conventional redo surgery for degenerated mitral valve prostheses and rings in a multicenter registry

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Abstract

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.

Section snippets

Methods

Ten German cardiac surgery centers of the Arbeitsgemeinschaft Leitender Krankenhausärzte (Study Group of Chief Surgeons) participated in this multicenter registry and provided data of 273 patients with DMVP/R, treated either with TM-ViV (79 patients) or with Re-MVR (194 patients) between 2014 and 2019. Patients with prosthetic endocarditis and failing mechanical prostheses were excluded. In-hospital records were analyzed retrospectively with use of propensity score (PS)-matching to improve data

Results

Study group consisted of 273 patients with DMVP/R, who underwent repeat mitral valve procedures. Of them, 79 were treated with TM-ViV implantations, and 194 underwent Re-MVR. To improve data homogeneity, a PS matching (PSM) was implemented, leading to formation of 79 matched patient pairs. The following presented data is a summary of results after PSM (Figure 1).

Regarding baseline characteristics, there were several differences between groups. Mean age was 74.73 years in the TM-ViV and

Discussion

According to the Annual Report of the German Society for Heart, Vascular, and Thoracic Surgery from 2019, in 77 German heart surgery centers approximately 6500 isolated mitral valve operations were performed, with a total mortality of 3.4%. In 65% of cases the mitral valve was repaired with a mortality of 0.8%, compared with MVR, which was associated with a mortality of 8.2%. A small group of 152 patients underwent transcatheter MVRs. Perioperative mortality in this group was 9.2%.8 Repeat

Conclusions

Repeat intervention for DMVP/R is associated with increased perioperative risk. Currently, redo surgery constitutes treatment of choice, despite known challenges inherent to this type of procedure. In this context, TM-ViV implantation might be an attractive alternative in patients with high or prohibitive risk. Although not capable of complete treatment of coexisting comorbidities, transcatheter therapy focusing solely on mitral prosthesis offers a benefit resulting from limited invasiveness.

References (20)

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Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.

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