Mitral Valve-in-Valve Implantation as an Elective or Rescue Procedure in High-Risk Patients

Abstract

Transapical transcatheter mitral valve-in-valve implantation (TA-MVIVI) for bioprosthetic valve failure is an emerging alternative to reoperation in high-risk patients. We report our outcomes in a patient population with a high proportion of cardiogenic shock. Retrospective review was performed of all patients undergoing TA-MVIVI with an Edwards Sapien (Edwards Life sciences, Irvine, CA) prosthesis at our center between the years 2013 and2017. Nineteen patients with bioprosthetic mitral valve failure were included (mean age 78 ± 12 years). All patients were New York Heart Association functional class III or greater; The Society of Thoracic Surgeons mean score was 22.0 ± 17.5. The TA-MVIVI was performed in the setting of cardiogenic shock in 12 of 19 patients (63%). The primary mechanism for valve failure was regurgitation in 58%, stenosis in 21%, and mixed in 21%. All patients underwent successful TA-MVIVI with no deaths, strokes, or myocardial infarctions at 30 days. Two patients had brief postprocedural cardiac arrest but had full recovery. Mean transmitral gradient decreased from 12 ± 5 mm Hg to 5 ± 3 mm Hg (p= 0.0005). There was 1 death from unknown causes within the first year (5.2%). At a mean follow-up of 339 days (range, 30 to 1291), trace transvalvular regurgitation had developed in 3 of 19 patients (15.8%). There was no paravalvular regurgitation. At last follow-up, 89.5% of patients were New York Heart Association class I or II. Transapical transcatheter mitral valve-in-valve implantation can safely be performed in a patient population with a high proportion of cardiogenic shock with favorable clinical outcomes.