Outcomes for Percutaneous Mitral Valve-in-Valves and Mitral Valve-in-Rings in the Transapical and Transseptal Access Routes: A Systematic Review and Pooled Analysis

Transseptal versus Transapical Transcatheter Mitral Valve-in-Valve and Valve-in-Ring Implantation: A Systematic Review and Meta-Analysis

OBJECTIVES

Transcatheter mitral valve replacement has become a useful alternative for patients with failed mitral prosthesis or annuloplasty rings who are deemed high risk for re-do surgery. We aimed to compare the clinical outcomes following transseptal (TS) and transapical (TA) approaches in transcatheter mitral valve-in-valve and valve-in-ring implantation (TMViV/R) METHODS: Electronic databases PubMed, MEDLINE, and Embase were searched through November 2022. Both clinical trials and observational studies comparing patients undergoing TS and TA TMViV/R were eligible for inclusion. Primary outcomes were 30-day and one-year mortality. Post-operative stroke, left ventricle outlet tract (LVOT) obstruction, mitral valve pressure gradient (MVPG), bleeding, and length of hospital stay were also evaluated.

RESULTS

Seven observational studies were included comparing patients undergoing TS (n=1875) and TA (n=1120) TMViV/R. The TS group had significantly lower 30-day mortality (OR: 0.66; 95% CI [0.47, 0.94]; P=0.02, I²= 0%) and lower one-year mortality risk group (HR: 0.79; 95% CI [0.63, 0.99]; P=0.04, I²= 0%) compared to the TA group. The TS group had consistent shorter in-hospital stay (MD= -3.79; 95% CI [-5.23, -2.34] days; p<0.0001, I²= 75%). Post-operative stroke, bleeding and LVOT obstruction tended to be lower in the TS but the results did not reach statistical significance. Post-operative MVPG was similar between both groups.

CONCLUSION

The TS approach has lower early mortality, lower one-year death hazard, shorter in-hospital stay, and a trend toward lower complication rates when compared to TA TMViV/R. Further controlled trials may support the evidence and provide long-term outcomes.

The 40th Anniversary of Percutaneous Balloon Valvuloplasty for Mitral Stenosis: Current Status

Percutaneous balloon mitral valvuloplasty (PBMV), once the most complex of percutaneous cardiac procedures and essentially the first adult structural heart intervention, set the stage for a host of new technologies. Randomized studies comparing PBMV to surgery were the first to provide a high-level evidence base in structural heart. The devices used have changed little in 40 years, but the advent of improved imaging and the expertise gained in interventional cardiology has provided some additional procedural safety. However, with the decline in rheumatic heart disease, PBMV is being performed in fewer patients in industrialized nations; in turn, these patients have more comorbidities, less favorable anatomy, and thus a higher rate of procedure-related complications. There remain relatively few experienced operators, and the procedure is distinct enough from the rest of the structural heart intervention world that it has its own steep learning curve. This article reviews the use of PBMV in a variety of clinical settings, the influence of anatomic and physiologic factors on outcomes, the changes in the guidelines, and alternative approaches. PBMV remains the procedure of choice in patients with mitral stenosis with ideal anatomy and a useful tool in patients with less than ideal anatomy who are poor surgical candidates. In the 40 years since its first performance, PBMV has revolutionized the care of mitral stenosis patients in developing countries and remains an important option for suitable patients in industrialized nations.