Five-Year Outcomes of Patients With Mitral Structural Valve Deterioration Treated With Transcatheter Valve in Valve Implantation – A Single Center Prospective Registry

The Valve-in-Valve (ViV) technique is an emerging alternative for the treatment of bioprosthetic structural valve deterioration (SVD) in the mitral position. We report on intermediate-term outcomes of patients with symptomatic SVD in the mitral position who were treated by transcatheter mitral valve-in-valve (TM-ViV) implantation during the years 2010–2019 in our center. Three main outcomes were examined during the follow-up period: NYHA functional class, TM-ViV hemodynamic data per echocardiography, and mortality. Our cohort consisted of 49 patients (mean age 77.4 ± 10.5 years, 65.3% female). The indications for TM-ViV were mainly for regurgitant pathology (77.6%). All 49 patients were treated with a balloon-expandable device. The procedure was performed via transapical access in 17 cases (34.7%) and transfemoral vein/trans-atrial septal puncture in 32 cases (65.3%). Mean follow-up was 4.4 ± 2.0 years. 98% and 91% of patients were in NYHA I/II at 1 and 5 years, respectively. Mitral regurgitation was ≥moderate in 86.3% of patients prior to the procedure and this decreased to 0% (p < 0.001) following the procedure and was maintained over 2 years follow-up. The mean trans-mitral valve gradients decreased from pre-procedural values of 10.1 ± 5.1 mmHg to 7.0 ± 2.4 mmHg at 1 month following the procedure (p = 0.03). Mortality at 1 year was 16% (95%, CI 5–26) and 35% (95%, CI 18–49) at 5 years. ViV in the mitral position offers an effective and durable treatment option for patients with SVD at high surgical risk.

A novel alternative: transapical transcatheter mitral valve-in-valve implantation using J-Valve for failed bioprosthesis

BACKGROUND

Failed mitral bioprosthesis has conventionally been treated with redo surgical mitral valve replacement (SMVR). Transcatheter mitral valve-in-valve implantation (TM-VIVI) is emerging as an alternative to SMVR in high-risk patients. We report our experience with transapical TM-VIVI using the J-Valve system.

METHODS

From May 2020 to January 2021, 21 patients with a failed mitral bioprosthesis underwent transapical TM-VIVI without concomitant procedures at Guangdong Provincial People's hospital. The mean age was 74.62 years. All patients were heavily symptomatic with severe mitral regurgitation and increased trans-prosthetic gradient. The Society of Thoracic Surgeons predicted risk of mortality (STS PROM) and European System for Cardiac Operative Risk Evaluation II (EuroScore II) scores were used and predicted high mortality (STS PROM, 12.91%±9.94%; EuroScore II, 12.04%±10.5%). All the procedures were performed in a hybrid room.

RESULTS

The success rate was 100% with no conversion to median sternotomy and no intraprocedural death. The mean ventilation time and intensive care unit (ICU) stay were 25±21.44 minutes and 4.14±7.08 days, respectively. No major postoperative complications were observed, except 1 patient suffered pneumonia and required tracheostomy. All patients recovered well. Postoperative echocardiography revealed excellent hemodynamics with no residual mitral regurgitation in 19 patients and mild regurgitation in 2 patients. In a subgroup analysis, no significant differences among procedural and postoperative outcomes were detected in patients with previous aortic-mitral double valve replacement (DVR) compared to other patients.

CONCLUSIONS

Our results demonstrate the safety and feasibility of transapical TM-VIVI using the J-Valve system, even in patients following DVR.

Long-term outcomes of a totally thoracoscopic approach for reoperative mitral valve replacement: a propensity score matched analysis

BACKGROUND

This study aimed to summarize the perioperative and long-term outcomes of patients with previous mitral valve surgery (MVS) undergoing reoperative mitral valve replacement (MVR).

METHODS

Data for all reoperative mitral valve replacements (re-MVRs) with or without concomitant tricuspid surgery were analyzed from Guangdong Provincial People's Hospital between January 2013 and December 2019. Propensity score matching resulted in 30 matched pairs with improved balance after matching in baseline covariates. Perioperative data and long-term clinical outcomes were analyzed.

RESULTS

Results are based on the matched cohorts between the two groups. The in-hospital mortality was 3.3% (two deaths) in the entire cohort and was not significantly different between the median sternotomy (MS) group and the totally thoracoscopic (TT) group. Most patients in the TT group had their tracheal intubation removed within 24 hours of surgery. The TT group had a diminished requirement for blood transfusion and a reduced 4-day postoperative chest tube drainage amount. The incidence of early major complications, including all-cause death and reoperation due to bleeding, was lower in the TT group. No significant differences were observed in the 7-year survival probability between the two groups.

CONCLUSIONS

The encouraging results regarding the perioperative and long-term outcomes of patients who underwent a TT re-MVR show that this approach is particularly beneficial for patients requiring reoperation.

Recent insights into pathophysiology and management of mechanical complications of myocardial infarction

PURPOSE OF REVIEW

Mechanical complications of myocardial infarction are a group of postischemic events and include papillary muscle rupture resulting in ischemic mitral regurgitation, ventricular septal defect, left ventricle free wall rupture, pseudoaneurysm, and true aneurysm. Advances made in management strategies, such as the institution of 'Code STEMI' and percutaneous interventions, have lowered the incidence of these complications. However, their presentation is still associated with increased morbidity and mortality. Early diagnosis and appropriate management is crucial for facilitating better clinical outcomes.

RECENT FINDINGS

Although the exact timing of a curative intervention is not known, emerging percutaneous and transcatheter approaches and improving mechanical circulatory support (MCS) devices have greatly enhanced our ability to manage and treat some of the complications postinfarct.

SUMMARY

Although the incidence of mechanical complications of myocardial infarction has decreased over the past few decades, these complications are still associated with high rates of morbidity and mortality. The combination of early and accurate diagnosis and subsequent appropriate management are imperative for optimizing clinical outcomes. Although more randomized clinical trials are needed, mechanical circulatory support devices and emerging therapeutic strategies can be offered to carefully selected patients.

Review of transapical off-pump mitral valve intervention with NeoChord implantation

PURPOSE OF REVIEW

Mitral valve repair surgery has recently shifted from resection-based techniques to leaflet sparing approaches using synthetic neochordae. This has facilitated the growth of a new strategy of transapical off-pump mitral valve intervention with neochord implantation.

RECENT FINDINGS

Minimally invasive approaches for mitral valve repair with robotic or video-assisted mini-right anterolateral thoracotomy have been developed to mitigate the morbidity associated with conventional median sternotomy. Recently, an alternative, less invasive surgical strategy has emerged. This transapical off-pump technique employs the NeoChord DS1000 (NeoChord, Inc., Minneapolis, MN, USA) system to achieve repair with neochordae via a left minithoracotomy incision. With appropriate patient selection, advanced cardiac imaging, and training in device deployment are important for procedural success.

SUMMARY

Early results suggest that transapical off-pump mitral valve intervention with NeoChord implantation is a safe procedure with favorable outcomes for select patients with degenerative mitral regurgitation. Continued experience and clinical trials will assess the potential of this minimally invasive strategy, but this technique is likely to become part of the surgical repertoire for managing chronic degenerative mitral valve disease.