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 high risk surgical patients. We aimed to analyze the mid-term outcomes of patients undergoing valve-in-valve (VIV) implantation in the mitral position.

Methods:
A dual center results in treating consecutive patients with structural bio-prosthetic mitral valve deterioration using the VIV technique via the trans-apical approach are presented . Outcomes were rigorously assessed and reported based on VARC 2 criteria definitions.

Results:
VIV operation was performed in 30 patients, age 76±12 years, STS score 10.7±6.0. Balloon-expandable Sapien devices were used in all patients. The composite endpoint of device success was achieved in all (100%) patients. The operative mortality was 3.5% (sepsis). Follow up (up to 6 years, mean 29 months) demonstrated 1y and 2y survival rates of 90% and 83.3%, respectively and remained constant afterwards. One patient had cardiovascular related mortality (endocarditis). Most of surviving patients (96%) are in NYHA-FC I/II. No valve migration was observed. The mitral regurgitation grade dropped post-operation and remained constant during follow-up (from 3.9±0.3 to 0.2±0.6 and 0.3±0.5, respectively, p<0.01). Post-operative and follow-up mean transvalvular mitral gradient was 6.4±3.0 mmHg and 6.3±1.6 mmHg, respectively, ns). Trans-mitral mean gradient in original deteriorated valve size 25 or 27 was similar to those patients with 29 or 31 valve (6.25±1.4 mmHg and 6.4±1.7 mmHg, respectively, ns). Only one patient had para-valvular leak (mild). The pre-operative pulmonary artery pressure decreased from 67.2±18.4 mmHg to 43.8±11.2 mmHg, p<0.01.

Conclusions:
Intermediate-term clinical outcomes of transcatheter VIV implantation for the treatment of mitral prosthetic valve deterioration in high risk patient are encouraging. Most patients experienced clinical improvement, despite residual gradients across the VIV which was unrelated to the original deteriorated valve size. This novel approach allows good survival rate and satisfactory functional class during mid-term follow-up period.