Percutaneous Trans-Septal Mitral Valve in Valve Implantation for the Treatment of Structural Valve Deterioration Procedural and Short-Term Follow-Up Outcomes

Background:

Mitral bio-prosthetic valve deterioration requiring valve replacement occurs in >30% of patients after mitral valve replacement (MVR). In patients at increased surgical risk, percutaneous mitral valve-in-valve (VIV) implantation is emerging as a safe alternative to re-do surgery.

We aim to describe our experience in the treatment of patients with severe mitral bio-prosthetic valve deterioration using the VIV approach via a percutaneous trans-septal access.

Methods and Results:

From February to November 2017, 13 patients underwent trans-septal mitral VIV implantation in our institution. Pre- intra- and post-procedural data were registered in a dedicated database. Mean follow up was 168 days.

Patients (N=13) (77% female) mean age was 76.5 years old. Baseline New York Heart Association – functional class (NYHA-FC) III/IV was present in 9(69%) of patients. The mean Society of Thoracic Surgeons score was 9.5%. Pre-procedural trans-esophageal echocardiogram (TEE) and gated cardiac CT was performed in 69% and 46% of patients; respectively. Severe bio-prosthetic mitral stenosis was present in 4 (31%) patients and severe mitral regurgitation in 9 (69%) patients. The mean time from surgical MVR to percutaneous VIV was 11.7 years. Two (15.3%) cases were performed on an emergency basis due to decompensated heart failure. The balloon expandable Edwards-Sapien 3 trans-catheter valve device was used in all patients. Cases were performed under general anesthesia. Procedural success was achieved in 100% of patients. Significant post-procedural left-to-right atrial shunt was present in 3(23%) patients and treated percutaneously. In-hospital mortality was 0%. The mean length of hospitalization was 3.9 days. NYHA-FC at one month follow-up was I and II in 8(66%) and 4 (33%) of patients; respectively. One patient (7.6%) died at 1 month follow-up.

Conclusion:

Percutaneous trans-septal mitral VIV implantation is safe and efficacious. A careful patient selection in the setting of the local “heart team” and procedural planning are conditions for the success of this novel therapeutic approach.