Transseptal or Transapical Transcatheter Valve-in-Valve Implantation Versus Redo Surgical Replacement for Degenerated Mitral Bioprostheses

  1. Pedro Felipe Gomes Nicz
  2. Mauricio Felippi de Sá Marchi
  3. Henrique Barbosa Ribeiro
  4. Fernando Chiodini Machado
  5. Roney Orismar Sampaio
  6. José Honório de Almeida Palma da Fonseca
  7. José Airton de Arruda
  8. Carlos Henrique Eiras Falcão
  9. Maurício Lopes Prudente
  10. Vitor de Andrade Vahle
  11. Arnaldo A Okino
  12. Marco Antônio Praça de Oliveira
  13. Maurílio Onofre Deininger
  14. Antenor Lages Fortes Portela
  15. Salvador André Bavaresco Cristovão
  16. Rodrigo de Castro Bernardes
  17. Breno de Alencar Araripe Falcão
  18. Estêvão Carvalho de Campos Martins
  19. Luiz Eduardo Koenig de São Thiago
  20. Adriano Dias Dourado Oliveira
  21. Fabio Solano de Freitas Souza
  22. Eduardo França Pessoa de Melo
  23. Antônio Carlos Botelho da Silva
  24. João Eduardo Tinoco de Paula
  25. Evandro Martins Filho
  26. Ari Mandil
  27. Mateus S Viana
  28. Rogério Sarmento-Leite
  29. Wilton Francisco Gomes
  30. Cristiano Guedes Bezerra
  31. Antonio José Neri de Souza
  32. Valter Correa Lima
  33. Moysés de Oliveira Lima-Filho
  34. Roger Renault Godinho
  35. Gabriela Liberato de Souza
  36. David Le Bihan
  37. Wilson Mathias
  38. Pablo Pomerantzeff
  39. Fábio Biscegli Jatene
  40. Roberto Kalil-Filho
  41. Flávio Tarasoutchi
  42. Azeem Latib
  43. Alexandre Abizaid
  44. Fábio Sandoli de Brito
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Abstract

Background

Bioprosthetic mitral valve degeneration can be problematic as redo surgical mitral valve replacement (Redo-SMVR) is associated with a high morbidity and mortality. Valve-in-valve transcatheter mitral valve replacement (TMVR) has emerged as an alternative for high-risk patients, but comparative data is lacking.

Objectives

We aimed to evaluate the outcomes of Redo-SMVR vs. TMVR, using either transapical (TA) or transseptal (TS) approach.

Methods and Results

A total of 415 patients (69% rheumatic) were included between January 2014 to May 2023 (Redo-SMVR=239; TA-TMVR=84; TS-TMVR=92). Patients in the Redo-SMVR group were younger (51.7±12.3, 64.3±10.5, 73.7±10.9, respectively for Redo, TA and TS; p<0.001) with a lower median STS score (2.9 [1.7 – 5.1], 6.6 [3.9–10.5], 6.5 [4.2–10.0]; p<0.001). 30-day mortality was significantly higher for both Redo-SMVR and TA-TMVR vs. TS-TMVR (14.2%, 15.5%, 4.3%; p=0.030) and procedural success was lower (52.5%, 64.9%, 88%; p<0.001). There was no difference in terms of 1-year mortality rate across the groups (Log-rank p=0.222). Reduced preprocedural left ventricular ejection fraction, higher right ventricular systolic pressure (RVSP), and the presence of coronary artery disease were independently associated with 30-day mortality, while transseptal approach was protective. At 1-year follow-up, the predictors of mortality remained consistent, with significant tricuspid regurgitation replacing RVSP (all with p<0.05).

Conclusions

In high-risk patients with dysfunctional mitral bioprosthesis and most with rheumatic etiology, TS-TMVR was associated with higher procedural success and better short-term outcomes, including all-cause mortality, despite higher risk characteristics. In the mid-term follow-up, there were no significant differences in mortality across the groups.

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  1. Version published to 10.1101/2025.04.08.25325495v1 on medRxiv