Treatment of Mitral Bio-Prosthetic Valve Deterioration Using Trans Apical Valve in Valve Technique: Intermediate-term Outcomes

Objective: The transcatheter approach for a failed bio-prosthetic valve is an emerging alternative to redo-valve surgery in patients at high surgical risk. We aim to analyze the mid-term outcomes of patients undergoing valve-in-valve implantation in the mitral position.

Methods: We report our clinical experience in treating consecutive patients with symptomatic structural bio-prosthetic mitral valve deterioration using the valve-in-valve technique via the trans-apical approach. Outcomes were rigorously assessed and reported based on VARC 2 criteria definitions.

Results: The valve-in-valve procedure in the mitral position was performed in 15 patients, mean age 75±12.7 years, mean STS score 10.0±7.3. Balloon-expandable Sapien XT devices were used in all patients. The composite endpoint of device success was achieved in 15/15 (100%) of patients. Post procedural mean mitral transvalvular gradient was 5.5±3.3 mmHg. No patients (0%) had ≥mild para-valvular leak. Follow up (up to 5 years, mean 29 months) demonstrated survival rates of 86%. One patient sustained a large intractable pleural effusion that needed repeated drainage and died of sepsis 34 days following the procedure. The second patient died 18 months after surgery from a non cardiac cause. All surviving patients (100%) were examined and are in NYHA-FC I/II. No valve migration was observed. The mean trans-mitral gradient was 7.2±2.3 mmHg, and the pre-operative pulmonary artery pressure decreased from 50.2±12.6 to 35.5±12.2 (p<0.01).

Conclusions: Intermediate-term clinical outcomes of transcatheter valve-in-valve implantation for the treatment of mitral prosthetic valve deterioration in high risk patient are encouraging. A residual elevated gradient across the valve were observed. This novel approach allows good survival rate and satisfactory quality of life during mid-term follow-up period.