Transcatheter Aortic and Mitral Valve-in-Valve Implantation for Failed Surgical Bioprosthetic Valves

Supra-Annular Self-Expanding Versus Balloon-Expandable Valves for Valve-in-Valve Transcatheter Aortic Valve Replacement

Self-expanding (SE) and balloon-expandable (BE) transcatheter heart valves (THVs) have not been extensively studied in valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). We compared outcomes of supra-annular SE and BE THVs used for ViV-TAVR through a retrospective analysis of institutional data (2013 to 2023) including all patients who underwent ViV-TAVR (TAVR in previous surgical aortic valve replacement). Unmatched and propensity-matched (1:1) comparisons of clinical and echocardiographic outcomes were undertaken in SE and BE THVs along with Kaplan-Meier survival analysis. A total of 315 patients who underwent ViV-TAVR were included, of whom 73% received an SE THV. Median age was 77 years, and women comprised 42.5% of the population. Propensity-score matching (1:1) yielded 81 matched pairs. Implanted aortic valve size was comparable in the groups (23 mm [23 to 26] vs 23 mm [23 to 26], p = 0.457). At 30 days after ViV-TAVR, the SE group had a lower mean aortic valve gradient (14 mm Hg [11 to 18] vs 17.5 mm Hg [13 to 25], p = 0.007). A greater number of patients with BE THV had severe prosthesis-patient mismatch (16% vs 6.2%, p = 0.04). At 1-year follow-up, the SE THV group had a lower aortic valve gradient (14.0 mm Hg [9.6 to 19] vs 17 mm Hg [13 to 25], p = 0.04) than that of the BE THV group; 30-day mortality was 2.7%, whereas 1-year mortality was 7.5% and comparable in the groups. Survival and stroke incidence were similar in the groups up to 5 years. In conclusion, SE and BE THVs had comparable survival after ViV-TAVR. The higher residual aortic valve gradients in BE THVs are likely due to valve design and warrant long-term evaluation for potential structural valve degeneration.

Successful transcatheter aortic valve replacement in a failing HAART 300 aortic valve annuloplasty ring: A case report

Transcutaneous aortic valve replacement (TAVR) has evolved from a complex procedure meant only for patients at prohibitive risk for surgery to a commonly performed procedure across a wide variety of clinical scenarios including the treatment of failed aortic valve bioprosthesis. Annuloplasty rings in the aortic position such as HAART 300 (Biostable Science and Engineering) have been introduced in the management of native aortic regurgitation. Percutaneous management of failed bioprosthesis rings in the aortic position has not been widely described. We present a case of a 69-year-old man with recurrent aortic regurgitation successfully treated with TAVR using a SAPIEN 3 valve within a HAART 300 ring.

2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.

Mitral re-valve-in-valve as a new perspective for high-risk patients with prosthetic valve dysfunction: case reports

Background

Mitral valve diseases are a common medical condition, and surgery is the most used therapeutic approach. The need for less invasive interventions led to the development of transcatheter valve implantation in high-risk patients. However, the treatment to the dysfunctions of these prosthetic valves is still uncertain, and the yield and safety of repeated transcatheter valve implantations remain unclear.

Cases summary

A 69-year-old Caucasian woman with three previous mitral valve procedures performed due to rheumatic valve disease (currently with a biological prosthetic mitral valve) and a 76-year-old Latin woman with previous liver transplantation (due to metabolic-associated fatty liver disease) and biological mitral prosthesis due to mitral valve prolapse with severe regurgitation underwent mitral valve-in-valve (ViV) transcatheter implantation at the time of dysfunction of their surgical prostheses. Later, these patients developed prosthetic valve dysfunction and clinical worsening, requiring another invasive procedure. Due to maintained high-risk status and unfavourable clinical conditions for surgery, re-valve-in-valve (re-ViV) was performed.

Discussion

Valve-in-valve transcatheter mitral valve implantation was approved in 2017, and, since then, it has been used in several countries, mainly in high-risk patients. Nevertheless, these prosthetic valves may complicate with stenosis or regurgitation, demanding reinterventions. Although there are favourable data for mitral ViV, re-ViV still lacks robust data to support its performance, with only case reports in the literature so far. It is possible that in high-risk patients, there is a greater benefit from re-ViV when compared with the surgical strategy. However, this hypothesis must be studied in future controlled trials.

Transcatheter valve-in-valve or valve-in-ring implantation with a novel balloon-expandable device in patients with bioprosthetic left side heart valves failure: 1-year follow-up from a multicenter experience

BACKGROUND

Transcatheter aortic and mitral valve-in-valve (ViV) or valve-in-ring (ViR) implantation into failed bioprosthetic heart valves (BHVs) or rings represents an appealing, less invasive, treatment option for patients at high surgical risk. Nowadays, few data have been reported on the use of balloon-expandable Myval (Meril Life Science, Vapi, India) transcatheter heart valve (THV) for the treatment of degenerated BHVs or rings. We aimed at evaluating the early and mid-term clinical outcomes of patients with left side heart bioprosthesis deterioration treated with transcatheter ViV/ViR implantation using Myval THV.

METHODS

97 consecutive patients with symptomatic, severe aortic(n=33) and mitral(n=64) BHVs/ring dysfunction underwent transcatheter aortic ViV and mitral ViV/ViR implantation with Myval THV.

RESULTS

Technical success was achieved in 95 (98%) of the patients. Two cases of acute structural trans-catheter mitral ViV/ViR dysfunction requiring a second THV implantation were reported. At 30-day, a significant reduction in prosthetic trans-valvular pressure gradients and increase in valve areas were seen following both aortic and mitral ViV/ViR implantation. Overall survival at 15 months (IQR 8-21) was 92%. Patients undergoing mitral ViV/ViR had a relatively worse survival compared with those undergoing aortic ViV implantation (89% vs. 97% respectively; HR:2.7,CI:0.33-22.7;p=0.34). At longest follow-up available a significant improvement in NYHA functional class I and II was observed in patients with aortic and mitral ViV/ViR implantation(93.8% and 92.1%).

CONCLUSIONS

Despite high surgical risk, transcatheter ViV/ViR implantation for failed left side heart bioprosthesis can be performed safely using Myval THV with a high success rate and low early and mid-term mortality and morbidity.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Mechanical prostheses and bioprosthetic prostheses have their own advantages and disadvantages. Mechanical ones are recommended for younger patients (<50 years old), and bioprosthetic ones are recommended for older patients (>70 years old). There is still debate regarding which kind of prosthesis is better for middle-aged patients (50 to 70 years old) receiving aortic valve replacement (AVR). To solve this problem, we conducted this meta-analysis. Given that only one randomized controlled trial (RCT) study was included, we conducted a subgroup analysis of RCT and propensity score matching (PSM) retrospective studies to reduce the bias.

METHODS

We systematically searched articles related to clinical outcomes of mechanical and bioprosthetic prostheses in middle-aged patients receiving AVR in the PubMed, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases. The published date was up to 1 October 2022. Studies were excluded if not only middle-aged patients were included, or if they lacked direct comparisons between mechanical and bioprosthetic prostheses.

RESULTS

In total, 22 studies with 32,298 patients were included in the final analysis. The results show that patients aged between 50 and 70 receiving AVR with mechanical prostheses achieved better long-term survival and fewer reoperations and valve-related events but suffered more with bleeding events. No significant difference could be found in terms of early mortality and long-term cardiac death. The same results could be observed in the subgroup analysis of RCT and PSM retrospective studies.

CONCLUSION

Both mechanical and bioprosthetic prostheses are beneficial to middle-aged patients undertaking AVR procedures. However, mechanical prostheses show better clinical outcomes in long-term survival and comorbidities. Individual recommendation is still necessary.

BAlloon expandable vs. SElf expanding transcatheter vaLve for degenerated bioprosthesIs: design and rationale of the BASELINE trial

BACKGROUND

Surgical aortic valve bioprostheses may degenerate over time and require redo intervention. Transcatheter aortic valve replacement (TAVR) is a less invasive alternative to redo surgery. The BAlloon Expandable vs. SElf Expanding Transcatheter VaLve for Degenerated BioprosthesIs (BASELINE) trial was designed to compare the performance of the balloon-expandable SAPIEN-3 Ultra and the self-expanding EVOLUT PRO+ valve systems in symptomatic patients with a failing surgical bioprosthesis.

METHODS

The BASELINE trial is an investigator-initiated, non-funded, prospective, randomized, open-label, superiority trial enrolling a total of 440 patients in up to 50 sites in 12 countries in Europe and North-America. The primary endpoint is device success at 30-days defined by the Valve Academic Research Consortium-3 Criteria as the composite of technical success, freedom from mortality, freedom for surgery or intervention related to the device or to a major vascular or access-related or cardiac structural complication with an intended performance of the valve (mean gradient <20 mmHg and less than moderate aortic regurgitation). The co-primary endpoint at 1 year is defined as the composite of all-cause death, disabling stroke, rehospitalization for heart failure or valve related problems. Independent Core Laboratories will conduct uniform analyses of echocardiography (pre-, post-, 1-year post-procedure), multi-sliced computed tomography (pre-, and if available post-procedure) and cine-fluoroscopy studies.

CONCLUSIONS

The BASELINE trial is a head-to-head comparative trial investigating the 2 most used contemporary transcatheter heart valves for the treatment of a failing surgical aortic bioprosthesis. (ClinicalTrials.gov number NCT04843072).

Valve-in-valve transcatheter aortic valve replacement versus redo aortic valve replacement: which procedure for which patient?

INTRODUCTION

Bioprosthetic aortic valves are increasingly being utilized in a younger population due to improved durability and possibility for future valve-in-valve replacement. This has resulted in a larger population of patients with bioprosthetic aortic valve degeneration requiring re-intervention. Despite no head-to-head comparisons between redo surgical aortic valve replacement (SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR), observational studies suggest a comparable long-term risk between which led to the incorporation of ViV TAVR to current guidelines.

AREAS COVERED

This article summarizes the comparative performance of redo SAVR versus ViV TAVR in patients with bioprosthetic valve dysfunction and provides a guide to better understand which procedure is best for which patient.

EXPERT OPINION

With the rising use of TAVR, we will be confronted with more bioprosthetic aortic valve degeneration requiring re-intervention. Based on the available evidence and expert consensus, we propose that patients with bioprosthetic aortic valve degeneration be treated with ViV TAVR if they have a history of radiation heart disease, prohibitive surgical risk, and multiple sternotomies; while patients with small prostheses, history of infective endocarditis, those at high risk for coronary obstruction, and those with need for other cardiac surgery will be managed with redo SAVR.

Real-world experience with concomitant or staged transcatheter aortic and mitral valve replacements using balloon-expandable valves

OBJECTIVE

To describe outcomes of patients who underwent transcatheter aortic valve replacement (TAVR) in a native valve or failed bioprosthetic valve or transcatheter heart valve (THV) and a transcatheter mitral valve replacement procedure (TMVR; valve-in-valve [mViV], valve-in-ring [mViR], and valve in mitral annulus calcification [ViMAC]) either concomitantly (same procedure) or staged (different procedures).

BACKGROUND

Patient characteristics, procedural details, and outcomes of concomitant or staged TAVR and TMVR procedures are largely unknown.

METHODS

Data were extracted from the STS/ACC TVT Registry™ for patients undergoing concomitant or staged TAVR and TMVR with SAPIEN XT, SAPIEN 3, or SAPIEN 3 Ultra (Edwards Lifesciences) THVs. Descriptive results were reported for procedural, index hospitalization, 30-day, and 1-year outcomes.

RESULTS

A total of 257 patients underwent TAVR and TMVR in concomitant (n = 135) or staged (n = 122) procedures. Device success was 82.9% and 83.9% for concomitant TAVR and TMVR procedures and 83.8% and 82.5% for staged TAVR and TMVR procedures. Significant improvements in aortic and mitral valve function remained stable through 1 year. All-cause mortality for concomitant and staged groups was 14.7% and 10.5% at 30 days, and 32.8% and 24.6% at 1 year, respectively. Stroke rate for concomitant and staged groups was 0.8% and 3.6% at 30 days and 3.9% and 5.6% at 1 year, respectively. Improvements from baseline to 1 year in NYHA class and KCCQ overall summary scores were observed for all patients.

CONCLUSIONS

Concomitant or staged transcatheter treatment of patients with aortic and mitral valve disease can be performed in select high-risk patients in experienced centers.

Transcatheter Mitral Valve Replacement in High-Surgical Risk Patients: A Single-Center Experience and Outcome

Background

Re-operative mitral valve (MV) replacement is a high-risk procedure, therefore, transcatheter MV replacement (TMVR) is a promising therapeutic option.

Aim

In this study, we aimed to evaluate the feasibility and safety of TMVR in patients with high surgical risk with degenerated mitral bioprostheses (TMViV), failed surgical rings (TMViR), and mitral annular calcification (TMViMAC).

Methods

This is a retrospective cohort study that enrolled patients with high surgical risk who underwent TMVR from February 2017 to September 2020. The TMVR procedure was performed using Edwards SAPIEN-3 valves through the transseptal approach.

Results

Sixty-four patients aged 62.7 ± 16.1 years with an STS score of 9.2 ± 3.7% underwent TMVR [35 (55%) TMViV, 16 (25%) TMViR, and 13 (20%) TMViMAC]. Mitral stenosis was more frequent in TMViV, mitral regurgitation was more frequent in TMViR, and combined mitral stenosis and regurgitation were more frequent in TMViMAC (P < 0.05). The MV gradient was 14.3 ± 5.3 mmHg and the MV area was 1.5±0.6 cm2. The 29 mm valve was frequently used in TMViV and TMViMAC, while the 23 mm valve was frequently used in TMViR (P=0.003 ∗ ). The procedural and fluoroscopy times were 58.7 ± 8.9 and 41.1 ± 8.2 minutes, respectively. Technical success was reported in 62 (98.4%) patients; 1 TMViR patient experienced valve embolization and salvage surgery, and 1 TMViMAC patient experienced slight valve malposition. At 3 months, 2 (3.1%) patients showed valve thrombosis (treated with anticoagulation), and 1 (1.6%) patient developed a paravalvular leak (underwent surgical MV replacement). At 6 months, 3 (4.7%) patients showed valve degeneration (underwent surgical MV replacement). Throughout follow-up, no patient exhibited mortality.

Conclusions

TMVR is a feasible and safe approach in patients with high surgical risk. TMViV and TMViR are reasonable as the first treatment approaches, and TMViMAC seems encouraging.

Challenges and Open Issues in Transcatheter Mitral Valve Implantation: Smooth Seas Do Not Make Skillful Sailors

According to the European and American guidelines, surgery represents the treatment of choice for mitral valve (MV) disease. However, a number of patients are deemed unsuitable for surgery due to a prohibitive/high operative risk. In such cases, transcatheter therapies aiming at MV repair have been proven to be a valuable alternative and have been recently introduced in the latest American guidelines on valvular heart disease. Indeed, percutaneous repair techniques, particularly transcatheter edge-to-edge, have gained a broad experience and demonstrated to be safe and effective. However, given the complexity and heterogeneity of MV anatomy and pathology, transcatheter MV implantation (TMVI) has grown as a possible alternative to percutaneous MV repair. Current data about TMVI are still limited and come from different settings: valve-in-native MV, valve-in-valve (ViV), valve-in-ring (ViR), and valve-in-mitral annular calcification. Preliminary data are promising although several open issues still need to be addressed. This paper provides a comprehensive review of the available devices in the different clinical settings, to discuss potentialities, limitations, and future directions for TMVI.

Left atrial geometry in an ovine ischemic mitral regurgitation model: implications for transcatheter mitral valve replacement devices with a left atrial anchoring mechanism

BACKGROUND

Transcatheter mitral valve replacement (TMVR) is a challenging, but promising minimally invasive treatment option for patients with mitral valve disease. Depending on the anchoring mechanism, complications such as mitral leaflet or chordal disruption, aortic valve disruption or left ventricular outflow tract obstruction may occur. Supra-annular devices only anchor at the left atrial (LA) level with a low risk of these complications. For development of transcatheter valves based on LA anchoring, animal feasibility studies are required. In this study we sought to describe LA systolic and diastolic geometry in an ovine ischemic mitral regurgitation (IMR) model using magnetic resonance imaging (MRI) and echocardiography in order to facilitate future research focusing on TMVR device development for (I)MR with LA anchoring mechanisms.

METHODS

A group of 10 adult male Dorsett sheep underwent a left lateral thoracotomy. Posterolateral myocardial infarction was created by ligation of the left circumflex coronary artery, the obtuse marginal and diagonal branches. MRI and echocardiography were performed at baseline and 8 weeks after myocardial infarction (MI).

RESULTS

Six animals survived to 8 weeks follow-up. All animals had grade 2 + or higher IMR 8 weeks post-MI. All LA geometric parameters did not change significantly 8 weeks post-MI compared to baseline. Diastolic and systolic interpapillary muscle distance increased significantly 8 weeks post-MI.

CONCLUSIONS

Systolic and diastolic LA geometry do not change significantly in the presence of grade 2 + or higher IMR 8 weeks post-MI. These findings help facilitate future tailored TMVR device development with LA anchoring mechanisms.

Access options for transcatheter mitral valve implantation in patients with prior surgical bioprosthesis

BACKGROUND

Transcatheter mitral valve-in-valve (TMVIV) procedure, either transapical (TA) or trans-septal (TS) has become a valuable alternative to conventional redo surgery in case of failing mitral bioprosthesis with good clinical outcomes. Here we present our fourteen-year institutional experience.

METHODS

All consecutive patients treated with TMVIV with either TA or TS access at our centre between July 2007 and July 2020 were included. Periprocedural and 30-day follow-up (FU) results are reported and TA and TS data are compared.

RESULTS

Eighty-two patients were included, of those 60 (73.2%) were TA while 22 (26.8%) were TS. Men represented 51.2% of the population with a mean age of 77.3±9.0 years. STS score and EuroSCORE II were 11.4%±6.2% and 11.5%±6.5% respectively. Baseline characteristics of TA and TS groups were comparable. TMVIV was performed at a median time of 9.3 years [interquartile range (IQR), 7.9-12.0 days] from the initial mitral valve surgery. Balloon expandable transcatheter heart valve (THV) prostheses (Edwards LifeSciences Corp., Irvine, CA, USA) were used exclusively. Technical success was 97.6% (96.7% and 100.0% for TA and TS respectively) with two (2.4%) periprocedural death, both in the TA group (P=0.533). We observed four (4.9%) left ventricular outflow tract (LVOT) obstructions with one being hemodynamically significant. Six (7.3%) major bleeding occurred in the TA group, not significantly different from TS group (P=0.279). The median length of stay was 6 days (IQR, 4-12 days, 1.5 vs. 7.0 days for TS and TA groups respectively, P=0.001). The overall 30-day mortality rate was 3.7%. We also observed three (3.7%) structural valve deteriorations and in one (1.2%) case the patient required redo mitral surgery at two months. Eighty-seven-point-eight percent of patients were I-II New York Heart Association (NYHA) class. At 30-day FU mean transmitral valve gradient was 7.3±2.7 mmHg and one patient (1.2%) had mitral regurgitation greater than mild. TA and TS groups were comparable.

CONCLUSIONS

Our 14-year single-center experience with TMVIV confirms procedural safety and is an effective alternative to redo surgery with comparable results with both TA and TS. With device, technical improvements and increasing operators' experience, TS is the preferred option for TMVIV. However, in some highly selected patient, TA may still play an important role.

"Gazing Into the Abyss": Transcatheter Mitral Valve-in-Valve Implantation Through a Cavernous Left Atrium

We describe the case of a 73-year-old woman presenting with heart failure, a degenerating bioprosthetic mitral valve, and severely dilated left atrium, and highlight the role of multimodality imaging in planning transseptal transcatheter mitral valve-in-valve implantation. (Level of Difficulty: Advanced.)

Causes and predictors of mortality after transcatheter mitral valve implantation in patients with severe mitral annulus calcification

OBJECTIVES

To evaluate the causes and predictors of mortality after valve-in-mitral annulus calcification (MAC) transcatheter mitral valve implantation (TMVI).

BACKGROUND

Conventional surgical mitral valve replacement is associated with a high risk in patients with mitral valve disease associated with severe MAC. In this population, TMVI may be an attractive alternative option. However, its prognostic factors are poorly understood.

METHODS

All patients undergoing valve-in-MAC TMVI from 2013 to 2018 in our center were included. Indication for TMVI relied on the judgment of the local heart team. Patients were followed at 30 days and 1 year.

RESULTS

A total of 34 patients underwent valve-in-MAC TMVI. The mean age was 79 ± 11 years and 73% of patients were women. Their mean EuroSCORE 2 was 8 ± 7%. The transseptal approach was used in 79% of patients and a hybrid transatrial in 29%. Balloon expandable transcatheter heart valves were used in all the patients. Technical success was achieved in 76% of the patients. Thirty-day and 1-year all-cause mortality rates were 14.7% and 32.4%, respectively. The main two causes of 1-year mortality were congestive heart failure (8.8%) and infective endocarditis (5.9%). In multivariate analysis, the only predictor of 1-year mortality was the presence of periprothetic mitral regurgitation grade 2 (HR, 5.69; 95%CI, 1.59-27.88, p = 0.032).

CONCLUSION

Early and mid-term mortality remains high after valve-in-MAC TMVI and seems to be associated with the presence of paravalvular mitral regurgitation. However, whether the latter is a prognostic factor or marker remains to be determined to improve clinical outcomes in this high-risk population.

Effects of Transapical Transcatheter Mitral Valve Implantation

Purpose: In this study, transapical transcatheter mitral valve-in-valve implantation (TAMVI) was compared with surgical redo mitral valve replacement (SRMVR) in terms of clinical outcomes.

Methods: We retrospectively identified patients with degenerated mitral bioprosthesis or failed annuloplasty rings who underwent redo SRMVR or TAMVI at our medical center. Clinical outcomes were based on echocardiography results.

Results: We retrospectively identified patients with symptomatic mitral bioprosthetic valve dysfunction (n = 58) and failed annuloplasty rings (n = 14) who underwent redo SRMVR (n = 36) or TAMVI (n = 36). The Society of Thoracic Surgeons Predicted Risk of Mortality scores were higher in the TAMVI group (median: 9.52) than in the SRMVR group (median: 5.59) (p-value = 0.02). TAMVI patients were more severe in New York Heart Association (p-value = 0.04). The total procedure time (skin to skin) and length of stay after procedures were significantly shorter in the TAMVI group, and no significant difference in mortality was noted after adjustment for confounding factors (p-value = 0.11). The overall mean mitral valve pressure gradient was lower in the TAMVI group than in the SRMVR group at 24 months (p < 0.01). Both groups presented a decrease in the severity of mitral and tricuspid regurgitation at 3–24 months.

Conclusions: In conclusion, the statistical analysis is still not robust enough to make a claim that TAMVI is an appropriate alternative. The outcome of the patient appears only to be related to the patient's pre-operative STS score. Additional multi-center, longitudinal studies are warranted to adequately assess the effect of TAMVI.

Transcatheter mitral valve thrombosis: A case report and literature review

Transcatheter mitral valve replacement (TMVR) is an exciting alternative therapy for complex patients with mitral valve disease. Experience with TMVR is new and there is a lot yet to discover about their durability, long-term outcomes, and complications including mitral transcatheter heart valve (THV) thrombosis. Many factors have been speculated to increased risk of THV thrombosis. Here, we report a case of a 72-year-old woman who developed mitral THV thrombosis after undergoing TMVR for severe mitral regurgitation with mitral annular calcification. We reviewed 42 TMVR papers with 1,484 patients, including 60 with mitral THV thrombosis. We discussed the most common strategies used for mitral THV thromboprophylaxis and treatment.

Evaluation of postoperative outcomes of valve reoperation: a retrospective study

OBJECTIVES

The aim of this study was to compare the incidence of operative death and postoperative complications between primary and reoperation valve surgeries and to identify independent risk factors for these events among valve-reoperation patients.

METHODS

Between 2013 and 2015, 54 269 patients who underwent valve surgery were retrospectively analyzed using the Japan Cardiovascular Surgery Database. They were divided into the primary (group P; n = 49 833) and reoperation (group R; n = 4436) surgery groups. Among the reoperation patients, we conducted multivariable logistic regression analyses to identify risk factors for the incidences of operative mortality and postoperative complications. Then, we also conducted propensity score matched analyses to compare the incidences of these 2 outcomes for primary versus reoperation procedures separately for patients with and without infective endocarditis (IE).

RESULTS

Incidences of postoperative mortality (4.6% vs 9.1%; P < 0.001) and any complications (36.6% vs 41.4%; P < 0.001) were higher in the reoperation group. For patients undergoing reoperation, strong risk factors for operative mortality included urgency status, ejection fraction <30%, IE, dialysis, chronic kidney disease, New York Heart Association class 3/4, concomitant coronary artery bypass grafting and aorta procedure, tricuspid valve surgery only, multivalve surgery and age. In the propensity score matched cohort, the relative odds of operative mortality were 1.53 (95% confidence interval: 1.26-1.86, P < 0.001) among patients with IE and were 1.58 (95% confidence interval: 1.18-2.13, P < 0.002) among those without.

CONCLUSIONS

Outcomes for reoperation were significantly worse than those for primary surgery. At the primary operation, the risk of reoperation should be considered and when considering the indications for reoperation, the preoperative state, surgical timing and intervention method should be considered.

Role of Cardiac CT in Pre-Procedure Planning for Transcatheter Mitral Valve Replacement

OBJECTIVES

This study sought to evaluate cardiac computed tomography (CCT) findings and their clinical impact among patients being considered for transcatheter mitral valve replacement (TMVR).

BACKGROUND

CCT is used to evaluate whether patients are candidates for TMVR, but limited data exist on the yield of such tests.

METHODS

Patients referred for pre-procedural CCT for TMVR planning in the context of failing mitral bioprosthetic valves, annuloplasty rings, and severe native valve disease with annular calcification were included in this study. CCT findings were analyzed to evaluate for suitability for TMVR. In the subset of patients who underwent TMVR, echocardiographic and procedural characteristics were recorded.

RESULTS

Among 80 patients who underwent pre-procedural CCT, the mean age was 71.8 ± 11.4 years, 60% were women, and the mean Society of Thoracic Surgeon score was 9.4 ± 6.7. Most cases were referred for valve-in-native annular calcification planning (n = 43), followed by valve-in-valve (n = 29), and valve-in-ring procedures (n = 8). A total of 51 (64%) patients did not undergo TMVR, 37 of whom had high-risk features identified on CCT. The most common reason for exclusion was related to large annular size, followed by heightened risk of left ventricular outflow tract (LVOT) obstruction. Among 29 patients (36%) who underwent TMVR, the 30-day mortality rate was 17%. Five patients experienced LVOT obstruction, 4 of whom were predicted by CCT. Following TMVR, 5 patients had at least moderate peri-valvular regurgitation.

CONCLUSIONS

A minority of patients referred for TMVR planning ultimately undergo the procedure. CCT identifies unsuitable anatomy and leads to exclusion in a significant number of cases.

Current and Future Application of Transcatheter Mitral Valve Replacement

Mitral valve anatomy is complex, and one size does not fit all. More recently, percutaneous mitral valve interventions have revolutionized the management of primary and secondary mitral regurgitation (MR). However, edge-to-edge leaflet repair is not suitable for a large proportion of individuals including those with a failing bioprosthetic mitral valve/annuloplasty ring, and patients with significant mitral annular calcification resulting in mixed mitral valve disease/mitral stenosis. For this high risk cohort, transcatheter mitral valve replacement seems to be an attractive alternative.

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 aortic valve replacement: An alternative for severe aortic stenosis

ABSTRACT

Transcatheter aortic valve replacement (TAVR) is considered a lower-risk procedure for patients with severe aortic valve stenosis. Several FDA-approved trials performed in the United States support TAVR to be beneficial over surgical aortic valve replacement in certain patient populations. An optimal TAVR program consists of a multidisciplinary team that selects candidates for the procedure based on shared decision-making and the patient's anatomy and risk factors, and follows the patients through the Transcatheter Valve Therapy National Registry.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Equipment entrapment during redo-TAVR with successful BASILICA procedure

Transcatheter aortic valve replacement (TAVR) for transcatheter heart valve failure has been suggested for high-risk patients. TAVR-in-TAVR, however, may lead to complex leaflet interactions causing coronary ostial obstruction, which is a devastating complication. Coronary protection with provisional stent placement may be challenging. We describe the first percutaneous transaxillary case of TAVR-in-TAVR with Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) where guide catheters used for coronary protection were entrapped between the valve frames. We describe anatomical predictors and management considerations. Operators should be aware of this important complication during TAVR-in-TAVR valve placement.

Incidence, Risk Factors, and Outcomes of Coronary Obstruction Following Valve-in-Valve Transcatheter Aortic Valve Replacement

There is scant information about the incidence, risk factors, and outcomes of coronary obstruction (CO) following valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). A meta-analysis of the published studies from January 2000 to April 2020 was conducted, and the endpoint was CO. A total of 2858 patients were enrolled in this study. The mean age was 77.7 ± 9.8, and 39.9% of them were female. The Society of Thoracic Surgeons (STS) score, European System for Cardiac Operative Risk Evaluation (EuroSCORE), and Logistic EuroSCORE were 8.9 ± 7.8, 16.0 ± 10.9, and 26.3 ± 16.3, respectively. The overall incidence of CO was 2.58%. CO incidence between patients with prior stented and stentless valves were significantly different (1.67% versus 7.17%), with an odds ratio (OR) of 0.25 and a 95% confidence interval (CI) of 0.14-0.44 (P < 0.00001). The first-generation valves were significantly associated with higher CO incidence compared with the second-generation valves (7.09% versus 2.03%; OR, 2.44; 95%CI, 1.06-5.62; P = 0.04), while no statistical difference was found between self-expandable valves and balloon-expandable valves (2.45% versus 2.60%; OR, 0.99; 95%CI, 0.55-1.79; P = 0.98). Virtual transcatheter to coronary ostia (VTC) distance (3.3 ± 2.1 mm, n = 29 versus 5.8 ± 2.4 mm, n = 169; mean difference, -2.70; 95%CI, -3.46 to -1.95; P < 0.00001) and the sinus of Valsalva (SOV) diameter (27.5 ± 3.8 mm, n = 23 versus 32.3 ± 4.0 mm, n = 101; mean difference, -3.80; 95%CI, -6.55 to -1.05; P = 0.007) were enormously shorter in patients with CO. The 24-hour, in-hospital, and 30-day mortality of patients with CO were 10.5%, 30.8%, and 37.1%, respectively. In conclusion, device selections, VTC distances, and SOV diameters may be important factors in assessing the CO risk in VIV-TAVR.

Mitral valve-in-valve and valve-in-ring: tips, tricks, and outcomes

Transcatheter aortic valve implantation is now a mainstay of treatment in patients with aortic stenosis who are considered intermediate, high and prohibitive risk for surgery. Extended use of this innovative platform in treating other conditions has led to its approval in treating degenerated aortic bioprosthesis. Similarly, use of transcatheter devices in treating degenerated mitral bioprosthesis and failed mitral valve repairs with annuloplasty rings has opened a potential alternative to surgery in these patients. Experience in mitral valve-in-valve (MVIV) and valve-in-ring (VIR), while still limited, is on the rise. Although similar in many ways to the aortic VIV, it is different with respect to patient selection, planning and procedural steps. Familiarity with the bioprosthetic properties and dimensions can help an operator choose an appropriate transcatheter device and deploy it in an ideal position. Due to greater variability in construction and properties, mitral rings have led to poorer results compared to mitral valve-in-valve. Understanding the properties of mitral rings is critical and has been simplified by us in a stepwise manner. We also describe steps in patient preparation and procedure, which should help operators in performing this procedure. Certain unique complications, such as left ventricular outflow tract obstruction and risk of embolization, are discussed with tips to address these issues. Once these steps are followed, the procedure can be performed with minimal risk and good outcome.

Valve-in-Valve and Valve-in-Ring Transcatheter Mitral Valve Implantation in Young Women Contemplating Pregnancy

Background:

Transcatheter mitral valve implantation (TMVI) is emerging as an alternative to surgical mitral valve replacement in selected high-risk patients. Delaying definitive mechanical mitral valve replacement and the constraints of anticoagulation thanks to TMVI may be an attractive option in young women contemplating pregnancy and suffering from failure of mitral bioprosthesis or annuloplasty. The aim of the study was to evaluate the possibility, safety, and outcomes of pregnancy after TMVI in this population.

Methods:

From 2013 to 2019, 12 young women contemplating pregnancy underwent transseptal valve-in-valve or valve-in-ring TMVI using the Edwards SAPIEN XT/3 valves and were prospectively followed up at 1 month, 6 months, 1 year, and yearly thereafter.

Results:

Mean age of the patients was 30±6 years. Bioprosthesis degeneration was observed in 7 cases and annuloplasty failure in 5. Three valve-in-ring patients required the implantation of a second valve, which led to an overall procedural success rate of 75%. One delayed left ventricular outflow tract obstruction required elective surgical mitral valve replacement. At 6 months/1 year, 83% of the patients were in New York Heart Association classes I/II. Mitral regurgitation was ≤2+ in all the cases and mean gradient was 7±2 mm Hg. Four patients could complete 6 full-term pregnancies. One symptomatic thrombosis occurred and resolved under aspirin and anticoagulation therapy. All others pregnancies were uneventful. Predelivery mean gradient was 11 mm Hg, and systolic pulmonary artery pressure was 32 mm Hg. There were 4 vaginal deliveries and 2 cesarians. Newborns were alive and healthy. At last follow-up, there was no death, and 3 patients required elective surgical mitral valve replacement at 6- to 54-month follow-up.

Conclusions:

Our study suggests that, in young women, transseptal TMVI to treat failing bioprostheses may result in good short-term outcomes that allow uneventful pregnancies. The results are less favorable in women with failed annuloplasty rings.

Transcatheter Valve-in-Valve Implantation With a Novel Balloon-Expandable Device in Patients With Bioprosthetic Heart Valve Failure: A Case Series

Trans-catheter valve-in-valve (ViV) is a treatment option for patients affected by bioprosthetic heart valve (BHV) failure. Both aortic and mitral ViV procedures present several challenges compared to native valve replacement. To date, no data concerning the balloon-expandable MyVal (Meril, Vapi, India) trans-catheter heart valve (THV) use in ViV procedure have been provided. In this case series, we described for the first time its use in five different BHV failures.

Transcatheter mitral valve replacement

Transcatheter mitral valve (MV) repair, specifically the edge-to-edge leaflet repair, is a less invasive treatment of symptomatic mitral regurgitation (MR) in patients with high or prohibitive surgical risk. In cases with severe leaflet calcification, small mitral orifice area, and/or extremely wide regurgitation across the entire MV commissure, transcatheter MV repair may rather cause suboptimal or potentially hazardous outcomes. In these cases, MV replacement can be a more suitable option. Recently, percutaneous transcatheter MV replacement has emerged as an acceptable therapeutic option for the treatment of degenerated surgical bioprosthetic disease. Moreover, several transcatheter devices for native MV replacement are under evaluation with a hope to provide more complete and reproducible restoration of MV function. In this article, we will review current status, applications, clinical outcomes, and limitations that need to be overcome for transcatheter MV replacement for both degenerated surgical bioprosthetic disease and native MV disorders.

The trans-septal approach in transcatheter mitral valve-in-valve implantation for degenerative bioprosthesis

Background

Transcatheter Mitral Valve-in-Valve Implantation (TMViVI) has recently emerged as a novel therapy for degenerated mitral valve bioprosthesis. Re-operative mitral valve surgery is associated with a substantial risk of mortality and morbidity. The objective of this study was to describe the outcomes of transcatheter mitral valve-in-valve implantations in our cardiac center.

Methods

Twenty-two patients underwent the valve-in-valve procedure because of bioprosthesis degeneration from March 2017 to October 2018. Clinical, echocardiographic, procedural details and survival at follow up were assessed.

Results

Eight patients refused re-operative cardiac surgery while others were deemed a high risk for conventional re-operative sternotomy. All patients had TMViVI performed via a trans-septal approach, and the prosthesis was implanted successfully with immediate hemodynamic improvement in 20 patients. One patient had tamponade (4.55%), two had permanent pacemaker insertion (9.09%), two patients had a renal impairment (9.09%), and three patients had vascular complications (13.64%). There was one aborted procedure for the failure to cross the tissue valve with a transcatheter valve, and one patient was converted to an emergency mitral valve surgery. All patients were discharged in NYHA class I/II and NYHA class was markedly improved at one-year follow-up (p = 0.002).

Conclusions

Trans-septal mitral valve-in-valve implantation can be performed safely for degenerative mitral valve bioprosthesis and with favorable early clinical and hemodynamic outcomes.

Minimally invasive and transcatheter approaches for mitral valve surgery

Mitral valve surgery has evolved through the ages, in response to prevalent epidemiology of mitral pathologies. In the modern era, advances in technology has allowed physicians to help a wider spectrum on increasingly sicker patients. This review summarises these advances and its associated evidence base for safety and efficacy.

Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches

PURPOSE OF REVIEW

With increasing use of prosthetic valves to treat degenerative valvular heart disease (VHD) in an aging population, the incidence and adverse consequences of paravalvular leaks (PVL) are better recognized. The present work aims to provide a cohesive review of the available literature in order to better guide the evaluation and management of PVL.

RECENT FINDINGS

Despite gains in operator experience and design innovation, significant PVL remains a significant complication that may present with congestive heart failure and/or hemolytic anemia. To date, clear consensus or guidelines on the evaluation and management of PVL remain lacking. Although the evolution of transcatheter valve therapies has had a tremendous impact on the management of patients with VHD, the limitations and complications of such techniques, including PVL, present further challenges. Incidence of PVL, graded as moderate or greater, ranges from 4 to 7.4% in surgical and transcatheter valve replacements, respectively. Improved imaging modalities and the advent of novel surgical and percutaneous therapies have undoubtedly yielded a better understanding of PVL including its anatomical location, mechanism, severity, and treatment options. Echocardiography, used in conjunction with cardiac computed tomography and cardiac magnetic resonance, provides essential details for diagnosis and management of PVL. Transcatheter intervention has become a favored approach in lieu of surgical intervention in select patients after previous surgical or percutaneous valve replacement. PVL treatment with vascular plugs, balloon post-dilation, and the valve-in-valve methods have shown technical success with promising clinical outcomes in appropriately selected patients.

Systematic review and meta-analysis of valve-in-valve transcatheter aortic valve replacement in patients with failed bioprosthetic aortic valves

AIMS

The aim of this meta-analysis was to evaluate the evidence regarding the rates of procedural success and the incidence of adverse outcomes following valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) in patients with failed bioprosthetic aortic valves.

METHODS AND RESULTS

A systematic search of major electronic databases was conducted for studies relevant to patients with failed bioprosthetic aortic valves undergoing VIV-TAVR. The primary outcome was procedural success. A total of 5,553 patients from 24 studies were included. The mean Society of Thoracic Surgeons (STS) score was 7.84±5.14. The procedural success rate was high (97%, 95% confidence interval [CI]: 94-98%). At 30 days, all-cause mortality was 5% (95% CI: 3-6%), stroke 2% (95% CI: 1-2%), myocardial infarction 1% (95% CI: 1-2%), permanent pacemaker placement 6% (95% CI: 5-8%), and aortic regurgitation 7% (95% CI: 5-10%). At one year, the incidence of all-cause mortality was 12% (95% CI: 10-14%), stroke 3% (95% CI: 2-4%), myocardial infarction 1% (95% CI: 0-2%), and permanent pacemaker placement 7% (95% CI: 5-11%). At three years, the incidence of all-cause mortality was 29% (95% CI: 25-34%) and stroke 6% (95% CI: 5-9%).

CONCLUSIONS

VIV-TAVR appears to be associated with high procedural success rates and low adverse outcomes during the short-term and midterm follow-up period.

Contemporary Reoperative Mitral Valve Surgery: Technical Considerations and Clinical Outcomes

As patients with cardiac disease live longer, reoperative mitral valve surgery has become more common. Although these operations are technically challenging and of high risk, outcomes continue to improve. Minimally invasive techniques, better cardioprotective strategies, and advanced perioperative care have contributed to this. In this review, we discuss surgical approaches, intraoperative strategies, novel catheter-directed devices, and clinical outcomes of contemporary reoperative mitral valve surgery.

Considerations for Optimal Device Selection in Transcatheter Aortic Valve Replacement: A Review

Importance

Aortic valve stenosis (AS) is the most common manifestation of acquired valvular heart disease in developed countries. Several large-scale randomized clinical trials investigating the entire spectrum of patients with severe symptomatic AS from low to prohibitive risk have established transcatheter aortic valve replacement (TAVR) as a safe and effective alternative to surgical aortic valve replacement.

Observations

There are currently only 3 types of TAVR devices commercially available in the US, but several other valve types are undergoing clinical trials in the US. Because of fundamental differences in engineering features, each TAVR device type has specific strengths and limitations. This review aims to provide an overview of design features and clinical outcomes of various TAVR devices that are either commercially available or undergoing clinical investigation.

Conclusions and Relevance

Given the lack of large-scale head-to-head comparisons of various TAVR devices and the rapid development of new device iterations, there is insufficient evidence to claim superiority of one device type over another. Nonetheless, as each TAVR device has unique design characteristics, certain patient-related and anatomy-related factors may slightly favor one or several particular designs.

Transcatheter heart valve interventions: where are we? Where are we going?

Transcatheter heart valve interventions have transformed the outcomes of patients with valvular heart disease (VHD) who are unfavourable candidates for surgery. Technological advances have allowed extension of these interventions to younger or lower risk patients and those with other forms of VHD and may in the future permit earlier treatment of VHD in less symptomatic patients or those with moderate disease. The balance of risks and benefits is likely to differ between lower and higher risk patients, and more evidence is needed to evaluate the net benefit of transcatheter technology in these groups. As academic researchers, clinicians, industry, and patient stakeholders collaborate to research these broader indications for transcatheter valve interventions, it is essential to address (i) device durability and deliverability, (ii) specific anatomical needs (e.g. bicuspid aortic valves, aortic regurgitation, mitral and tricuspid valve disease), (iii) operator training, and (iv) the reinforced importance of the multidisciplinary Heart Team.

Transesophageal echocardiography guidance of percutaneous mitral valve replacement in failed annuloplasty ring: A case report

Severe mitral regurgitation and stenosis due to failed mitral annuloplasty ring can be managed with percutaneous mitral valve in ring in high surgical risk patients. A 66-year-old male underwent coronary artery bypass surgery and mitral valve ring annuloplasty 7 years previously. He started to have shortness of breath with minimal effort in the past 2 years. Transthoracic echocardiogram revealed a new severe mitral regurgitation and severe mitral stenosis. The patient was turned down from surgery due to high surgical risk. The transcatheter mitral valve in ring implantation was decided. In this case, there was a low probability of left ventricular outflow tract obstruction. A stiff wire crossed the mitral valve ring and positioned in the left ventricular apex. The Sapien 3 valve size 26 mm (Edwards Lifesciences, Irvine, CA, USA) was positioned to have 80% ventricular and 20% atrial side. Transesophageal echocardiogram evaluation revealed a mean gradient of 5 mmHg. The left ventricular outflow tract (LVOT) had laminar color flow and the mean pressure gradient across LVOT was 1 mmHg. The patient was discharged after 2 days in good condition. At one year follow up, he had no shortness of breath and no rehospitalization. In conclusion, the percutaneous mitral valve in ring is feasible in selected patients. The risk of LVOT obstruction should be assessed carefully before the procedure with a transthoracic and transesophageal echocardiogram. 〈Learning objective: Understand how to guide the mitral valve in ring procedure with a transesophageal echocardiogram and how to avoid left ventricular outflow tract obstruction. Understand how to position the Sapien valve in mitral valve ring.〉.