Bioprosthetic Mitral Valve Dysfunction Research Articles

Impact and limitations of 3D computational modelling in transcatheter mitral valve replacement-atwo-centre Dutch experience.

Transcatheter mitral valve replacement (TMVR) has emerged as aminimally invasive alternative to mitral valve surgery for patients at high or prohibitive operative risk. Prospective studies reported favourable outcomes in patients with annulus calcification (valve-in-mitral annulus calcification; ViMAC), failed annuloplasty ring (mitral valve-in-ring; MViR), and bioprosthetic mitral valve dysfunction (mitral valve-in-valve; MViV). Multi-slice computed tomography (MSCT)-derived 3D-modelling and simulations may provide complementary anatomical perspectives for TMVR planning. We aimed to illustrate the implementation of MSCT-derived modelling and simulations in the workup of TMVR for ViMAC, MViR, and MViV. For this retrospective study, we included all consecutive patients screened for TMVR and compared MSCT data, echocardiographic outcomes and clinical outcomes. Sixteen out of 41patients were treated with TMVR (ViMAC n = 9, MViR n = 3, MViV n = 4). Eleven patients were excluded for inappropriate sizing, 4for anchoring issues and 10for an unacceptable risk of left ventricular outflow tract obstruction (LVOTO) based on 3D modelling. There were 3procedure-related deaths and 1non-procedure-related cardiovascular death during 30days of follow-up. LVOTO occurred in 3ViMAC patients and 1MViR patient, due to deeper valve implantation than planned in 3patients, and anterior mitral leaflet displacement with recurrent basal septum thickening in 1patient. TMVR significantly reduced mitral mean gradients as compared with baseline measurements (median mean gradient 9.5(9.0-11.5) mm Hg before TMVR versus 5.0(4.5-6.0) mm Hg after TMVR, p = 0.03). There was no residual mitral regurgitation at 30days. MSCT-derived 3D modelling and simulation provide valuable anatomical insights for TMVR with transcatheter balloon expandable valves in ViMAC, MViR and MViV. Further planning iterations should target the persistent risk for neo-LVOTO.

Clinical Characteristics and Long-Term Outcome of Patients with Bio-Prosthetic Mitral Valve – Experience From a South Asian Country

Objectives: The aim of this study is to evaluate clinical characteristics and long-term outcome of the patients with bio-prosthetic mitral valve replacement at a tertiary care hospital of a South Asian country.
 Methodology: The study is a retrospective observational observational study involving patients who underwent bio-prosthetic mitral valve replacement at a tertiary care hospital in Karachi, Pakistan, between 2006 and 2020, and had at least two complete echocardiograms. Patients with incomplete clinical data, no electronic reports of echocardiograms, and mechanical mitral valve replacement were excluded.
 Results: This is a retrospective observational study, conducted at a tertiary care hospital. We included a total of 502 patients who underwent bio-prosthetic mitral valve replacement from the year 2006 to 2020. Patients were divided into two groups based on normal functioning bio-prosthetic mitral valve and bio-prosthetic mitral valve dysfunction (BMVD). Out of 502 patients, 322 (64%) were female, mean age at the time of surgery was 49.42 ± 14.56 years. Mitral regurgitation was more common, found in 279 (55.6%) patients followed by mitral stenosis in 188 (37.5%) patients. Mitral valve replacement was done as an elective procedure due to NYHA II to IV symptoms at the time of surgery in 446 (88.8%) patients. In the mean follow-up of 6.59 + 2.99 years, bio-prosthetic mitral valve dysfunction (BMVD) was observed in 183 (36.5%) patients. However, re-do mitral valve surgery was done in only 49 (9.8%) patients. Comparing the two groups, individuals with normal functioning bio-prosthetic mitral valve had a mean age of 51.6 + 14.27 years, while those with BMVD had a mean age of 45.639 + 14.33 years at the time of index surgery (p value=0.000). There were more long-term complications including heart failure (n = 16, 8.74%), atrial fibrillation (n = 11, 6.01%) and death (n = 6, 3.28%) in BMVD group which were statistically significant.
 Conclusion: This study is distinct because it demonstrates the outcomes of bio-prosthetic valve replacement in a relatively younger South Asian population. Due to rapid degeneration of bio-prosthetic valve in younger patients, a significant number of cases developed BMVD along with poor long-term clinical outcomes even at a short follow up period of less than ten years. These findings are like international data and signify that mechanical mitral valve replacement may be a more reasonable alternative in younger patients.

COMPARISON OF PROPENSITY SCORES FOR SURGICAL TREATMENT OF BIOPROSTHETIC MITRAL VALVE DYSFUNCTION USING TRADITIONAL AND “VALVE-IN-VALVE” METHODS

HighlightsThe article describes the first conducted pseudorandomized comparative study of mitral valve replacement using either traditional or “valve-in-valve” techniques. AbstractAim. To compare short-term (perioperative) and medium-term (6 months) outcomes of surgical treatment of bioprosthetic mitral valve dysfunction using traditional and “valve-in-valve” methods.Methods. The study included 18 patients undergoing “valve-in-valve” replacement and 18 patients undergoing traditional mitral valve replacement (open mitral valve replacement) chosen according to the following criteria: heart disease type, predominant type of defect, age, gender, severity of the disease and the presence of concomitant pathology and using 1:1 matching on the propensity score.Results. No perioperative mortality was noted in both groups. The cardiopulmonary bypass and cross-clamping of the aorta time was significantly lower in the “valve-in-valve” group. Comparison of echocardiographic parameters revealed a decrease in the mean pulmonary arterial pressure gradient, and a decrease in the size of the heart chambers in both groups. The peak and mean transvalvular gradient were lower in the “traditional” group. There were no cases of patient-prosthesis mismatch. In the mid-term period, patients in both groups presented with a lower functional class of heart failure.Conclusion. Bioprosthetic mitral valve replacement using the “valve-in-valve” technique provides comparable clinical and hemodynamic results compared to the “traditional” technique in short-term and mid-term periods, and significantly reduces cardiopulmonary bypass and aortic cross clamping time.

Meta-Analysis Comparing Valve-in-Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement in Degenerated Bioprosthetic Mitral Valve

Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are 2 treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR. We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random-effects model to calculate odd ratios (ORs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding, acute kidney injury, arrhythmias, permanent pacemaker insertion, and hospital length of stay (LOS). A total of 6 observational studies with 707 subjects were included. The median follow-up was 2.7years. Despite their older age and greater co-morbidity burden, patients who underwent ViV-TMVR had a similar in-hospital mortality (OR 0.52, 95% CI 0.22 to 1.23,p=0.14), 30-day mortality (OR 0.65, 95% CI 0.36 to 1.17,p=0.15), 1-year mortality (OR 0.97, 95% CI 0.63 to 1.49, p=0.89), and 2-year mortality (OR 1.17, 95% CI 0.65 to 2.13, p=0.60) compared with redo-SMVR. ViV-TMVR was associated with significantly lower periprocedural complications, including stroke, bleeding, acute kidney injury, arrhythmias, and permanent pacemaker insertion, and shorter hospital LOS than redo-SMVR. In conclusion, ViV-TMVR was associated with better outcomes than redo-SMVR in patients with degenerated bioprosthetic mitral valves, including lower complication rates and shorter hospital LOS, with no significant difference in mortality rates. Large-scale randomized trials are needed to mitigate biases and confirm our findings.

Abstract 13462: Valve-in-Valve Transcatheter Mitral Valve Replacement versus Redo Surgical Mitral Valve Replacement for Degenerated Bioprosthetic Valves: A Systematic Review and Meta-Analysis

Introduction: Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are two treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR. Methods: We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding and vascular complications, acute kidney injury (AKI), arrhythmias, and hospital length of stay (LOS). Results: Six observational studies with a total of 1,339 subjects were included. Median follow-up was 2 years. Compared to redo-SMVR, ViV-TMVR was associated with significantly lower in-hospital (RR 0.42; 95% CI 0.25-0.70; p=0.001) and 30-day mortality (RR 0.49; 95% CI 0.24-0.98; p=0.04) but similar 1-year (RR 0.97; 95% CI 0.64-1.47; p=0.89) and 2-year mortality (RR 1.14; 95% CI 0.71-1.81; p=0.59). Stroke, bleeding, AKI, and arrhythmias were less frequent and hospital LOS was shorter with ViV-TMVR, however vascular complications were similar between both strategies. Conclusion: In patients with degenerated bioprosthetic mitral valves, ViV-TMVR is associated with better outcomes compared to redo-SMVR including lower in-hospital and 30-day mortality, lower complication rates, and shorter hospital LOS. Given these findings and the ongoing advances in transcatheter therapeutics, ViV-TMVR may be preferred over redo-SMVR, particularly in individuals at intermediate-to-high surgical risk.

Risk factors and outcomes with surgical bioprosthetic mitral valve dysfunction

BackgroundThere are insufficient data regarding the risk factors associated with valve dysfunction of bioprosthetic valves in the mitral position This study aimed to investigate the factors associated with bioprosthetic mitral...

Abstract 13256: Factors Determining Mitral Valve Dysfunction in Patients Who Underwent Surgical Mitral Valve Replacement With Bio-Prosthetic Valves

Introduction: There is increasing interest in bio-prosthetic MVD as recent advances in transcatheter MV interventions, but there is limited data. We sought to identify the factors determining mitral valve (MV) dysfunction (MVD) in patients who underwent MV replacement with bio-prosthetic valves and sought to clinical outcomes in patients with bio-prosthetic MVD. Hypothesis: MVD was related to younger age, renal dysfunction, postoperative elevated mean diastolic pressure gradient across the bio-prosthetic MV and anemia. Methods: A total of 233 patients underwent surgical bio-prosthetic MV replacement between June 1996 and May 2015. Finally, 226 patients (mean age 66.9±11.5 years, 74.3% of women) were analyzed. MVD was defined as an increase in mean gradient ≥ 5 mmHg with leaflet motion limitation and/or newly developed MV regurgitation during follow-up. Clinical outcome was defined as a composite of CV death, redo MV surgery or intervention, and hospitalization for heart failure. Results: During a median of 102 months (IQR 72 to 132 months), 65 patients (28.8%) revealed MVD. Factors associated with bio-prosthetic MVD were young age at operation (HR 0.97, 95% CI 0.95-0.99, p=0.001), end-stage renal disease (HR 4.29, 95% CI 1.45-12.71, p=0.007), elevated MDPG >5.5 mmHg early after operation (HR 1.86, 95% CI 0.97-3.74, p=0.063) and anemia after operation (HR 0.84, 95% CI 0.74-0.95, p=0.007). Kaplan-Meier curves revealed significant differences in event-free survivals for the occurrence of bio-prosthetic MVD according to each factor ( Figure 1 ). Patients with bio-prosthetic MVD showed significantly poor clinical outcomes compared with those without bio-prosthetic MVD (EFS 43.1% vs. 91.9%, log-rank p<0.001) during the follow-up. Conclusions: Young age at operation, ESRD, elevated MDPG and anemia after operation were associated with bio-prosthetic MVD in patients who underwent bio-prosthetic MV replacement.

Abstract 14148: Transcatheter Mitral Valve Replacement: A Single Center Tertiary Care Experience

Background: Transcatheter mitral valve replacement (TMVR) using transcatheter aortic valves is considered an advanced structural heart procedure performed at comprehensive valve centers in patients with degenerated mitral valve prostheses. We present our single-center experience of patients undergoing Valve in Valve (ViV) and Valve in Ring (ViR) TMVR. Methods: We identified patients who underwent the TMVR procedure at our center from 1/1/2017 to 12/31/2020. We analyzed baseline characteristics, STS-PROM score, functional status (NYHA and KCCQ), baseline laboratory values, echocardiographic parameters (including LVEF, MV area, gradient, grading of MS and MR was collected. Follow-up data on functional status, echocardiographic parameters, and mortality were collected at 30 days and 1-year post-procedure. Results: A total of 32 patients were identified during this time period. 70.5 % were females, 96.8 % Caucasian. Mean NYHA class was 3.25, STS-PROM was 6.25% (5.56-9.43), and KCCQ score of 38.04 (SD 19.9). 94 % (30) of patients had a previous history of MV replacement and 6 % (2) of them had a history of MV repair. Baseline mean LVEF was 57% (46.5-67), at 30 days 55% (47.5-64.5) at 1 year 53.5% (46.5-58.25). NYHA decreased from 3.25 (1-4) to 2 (1-2) at 30 days and 2 (1.5-2) at 1 year with KCCQ following a similar trend. MV area at baseline was 1.2 (0.66-1.63) which increased to 1.45 (SD 0.44) at 30 days and 1.63 (SD 0.4) at 1 year. MV mean gradient decreased from 12.43 (SD 5.2) to 8 (7-10) at 30 days and remained stable at 9 (6-11) at 1 year. MR gradient decreased from severe MR in 11 patients (35.48 5 at baseline) to 6 (18.75 %) and 0 at 1 year. TR gradients followed the trend. The mortality rate at 30 days was 6.25 % (2) and 15.62% (5) at 1 year. Conclusion: TMVR offers acceptable outcomes in patients with symptomatic bioprosthetic mitral valve dysfunction. Follow-up data at 30 days and 1 year demonstrates improvement in functional status and sustained decrease in mitral valve gradients.

Factors determining mitral valve dysfunction in patients who underwent surgical mitral valve replacement with bio-prosthetic valves

Abstract Background There is increasing Interest in bio-prosthetic MVD as recent advances in transcatheter MV interventions, but there is limited data. Objectives The aim of this study was to identify the factors determining mitral valve (MV) dysfunction (MVD) in patients who underwent MV replacement with bio-prosthetic valves. Also, we sought to investigate clinical outcomes in patients with bio-prosthetic MVD. Methods A total of 233 patients underwent surgical bio-prosthetic MV replacement between June 1996 and May 2015. Finally, 226 patients (mean age 66.9±11.5 years, 74.3% of women) were analyzed, excluding patients who followed-up for less than 5 years and patients whose baseline or follow-up echocardiography could not be analyzed. Clinical, echocardiographic, and laboratory data were collected early after the surgery and during follow-up. MVD was defined as an increase in mean gradient ≥5 mmHg with leaflet motion limitation and/or newly developed MV regurgitation during follow-up. Clinical outcome was defined as a composite of cardiovascular death, redo MV surgery or intervention, and hospitalization for heart failure. Results During a median of 102.0 months (interquartile range 72.0 to 132.0 months), 65 patients (28.8%) revealed MVD. 8 (12.3%) patients revealed predominant MV obstruction, and 57 (87.7%) showed predominant MV regurgitation. Factors associated with bio-prosthetic MVD by multivariate regression analysis were young age at operation (hazard ratio 0.97, 95% CI 0.95–0.99, p=0.001), end-stage renal disease (hazard ratio 4.29, 95% CI 1.45–12.71, p=0.007), elevated mean diastolic pressure gradient>5.5 mmHg across the bio-prosthetic MV early after operation (hazard ratio 1.86, 95% CI 0.97–3.74, p=0.063) and anemia after operation (hazard ratio 0.84, 95% CI 0.74–0.95, p=0.007). However, the presence of hypertension, dyslipidemia, or porcine bio-prosthesis was not related to the bio-prosthetic MVD. Kaplan-Meier curves revealed significant differences in event-free survivals for the occurrence of bio-prosthetic MVD according to each factor (Figure 1). Patients with bio-prosthetic MVD showed significantly poor clinical outcomes compared with those without bio-prosthetic MVD (event-free survival 43.1% vs. 91.9%, log-rank p<0.001) during the follow-up. Conclusions Young age at operation, end-stage renal disease, elevated mean pressure gradient early after the operation, and anemia after operation were associated with bio-prosthetic MVD in patients who underwent bio-prosthetic MV replacement. Funding Acknowledgement Type of funding sources: None.

Meshalkin National Medical Research Center

We present three cases of successful transatrial transcatheter valve-in-valve implantation in patients with bioprosthetic mitral valve dysfunction. Patients with a high surgical risk, with severe heart failure due to bioprosthetic mitral valve dysfunction, were implanted with transcatheter prostheses using the transatrial approach.Transesophageal echocardiography and fluoroscopy-guided transcatheter mitral prosthetic valve positioning was performed. With a cardiac pacing at 180 bpm, a transcatheter valve was implanted. The transcatheter valves functioned properly after surgery. The patients were discharged in satisfactory condition.

Percutaneous Transseptal Bioprosthetic Implantation in Failed Prosthetic Surgical Mitral Valve - Brazilian Multicenter Experience.

ResumoFundamento A intervenção percutânea em pacientes com disfunção de prótese biológica mitral apresenta-se como uma alternativa ao tratamento cirúrgico convencional.Objetivo Relatar a primeira experiência brasileira de implante transcateter de bioprótese valve-in-valve mitral via transeptal (TMVIV-via transeptal).Métodos Foram incluídos pacientes portadores de disfunção de bioprótese cirúrgica submetidos ao TMVIV-transeptal em 12 hospitais brasileiros. Foram considerados estatisticamente significativos valores de p<0,05.Resultados Entre junho/2016 e fevereiro/2019, 17 pacientes foram submetidos ao TMVIV-via transeptal. A mediana de idade foi 77 anos (IIQ,70-82), a mediana do escore STS-PROM foi 8,7% (IIQ,7,2-17,8). Todos os pacientes tinham sintomas limitantes de insuficiência cardíaca (CF≥III), tendo 5 (29,4%) sido submetidos a mais de uma toracotomia prévia. Obteve-se sucesso do TMVIV-via transeptal em todos os pacientes. A avaliação ecocardiográfica demonstrou redução significativa do gradiente médio (pré-intervenção, 12±3,8 mmHg; pós-intervenção, 5,3±2,6 mmHg; p<0,001), assim como aumento da área valvar mitral (pré-intervenção, 1,06±0,59 cm2; pós-intervenção, 2,18±0,36 cm2; p<0,001) sustentados em 30 dias. Houve redução significativa e imediata da pressão sistólica de artéria pulmonar, com redução adicional em 30 dias (pré-intervenção, 68,9±16,4 mmHg; pós-intervenção, 57,7±16,5 mmHg; 30 dias,50,9±18,7 mmHg; p<0,001). Durante o seguimento, com mediana de 162 dias (IIQ, 102-411), observou-se marcada melhora clínica (CF≤II) em 87,5%. Um paciente (5,9%) apresentou obstrução de via de saída de ventrículo esquerdo (VSVE), evoluindo para óbito logo após o procedimento, e outro morreu aos 161 dias de seguimento.Conclusão A primeira experiência brasileira de TMVIV-transeptal demonstra a segurança e a efetividade dessa nova técnica. A obstrução da VSVE é uma complicação potencialmente fatal, reforçando a importância da seleção dos pacientes e do planejamento do procedimento. (Arq Bras Cardiol. 2020; 115(3):515-524)

Doppler Parameters Derived from Transthoracic Echocardiography Accurately Detect Bioprosthetic Mitral Valve Dysfunction

Detecting bioprosthetic mitral valve dysfunction on transthoracic echocardiography can be challenging because of acoustic shadowing of regurgitant jets and a wide normal range of transvalvular gradients. Several studies in mechanical mitral valves have demonstrated the utility of the transthoracically derived parametersE (peak early mitral inflow velocity), pressure half-time, and the ratio of mitral inflow velocity-time integral(VTIMV) to left ventricular outflow tract velocity-time integral (VTILVOT) in detecting significant prostheticdysfunction. Uncertainty exists as to their applicability and appropriate cutoff levels in bioprosthetic valves. This study was designed to establish the accuracy and appropriate normal limits of routinely collected transthoracic Doppler parameters when used to assess bioprosthetic mitral valve function. A total of 135 clinically stable patients with bioprosthetic mitral valves who had undergone both transthoracic and transesophageal echocardiography within a 6-month period were retrospectively identified from the past 11years of the echocardiography database. Transthoracic findings were labeled as normal (n=81), regurgitant (n=44), or stenotic (n=10) according to the patient's transesophageal echocardiographic findings. Univariate and multivariate analyses were performed to identify Doppler parameters that detected dysfunction; then receiver operating characteristic curves were created to establish appropriate normal cutoff levels. The VTIMV/VTILVOT ratio was the most accurate Doppler parameter at detecting valvular dysfunction, with a ratio of >2.5 providing sensitivity of 100% and specificity of 95%. E>1.9m/sec was slightly less accurate (93% sensitivity, 72% specificity), while a pressure half-time of >170msec had both 100% specificity and sensitivity for detecting significant bioprosthetic mitral valve stenosis, (although it did not differentiate between regurgitant and normal). This study demonstrates that Doppler parameters derived from transthoracic echocardiography can accurately detect bioprosthetic mitral valve dysfunction. These parameters, particularly a VTIMV/VTILVOT ratio of >2.5, are a sensitive way of selecting patients to undergo more invasive examination with transesophageal echocardiography.

Valve-in-Valve Transcatheter Valve Implantation in the Nonaortic Position.

Transcatheter valve-in-valve (VIV) procedures are an alternative to standard surgical valve replacement in high risk patients. Cases in which a commercially approved transcatheter aortic valve replacement (TAVR) device was used for a nonaortic VIV procedure between November 2013 and September 2015 are reviewed. Clinical, echocardiographic, and procedural details, patient survival, and symptom severity by NYHA class at follow-up were assessed. All patients were heart-team determined high risk for conventional redo surgery (mean STS PROM = 6.8 ± 2.2%). Five patients underwent VIV replacement in the nonaortic position, four for bioprosthetic mitral valve dysfunction, and one for bioprosthetic tricuspid valve dysfunction. Bioprosthetic failure was due to stenosis in three patients and regurgitation in two others. A balloon-expandable device was used for all patients (Edwards Lifesciences, Irvine, CA, USA). Transcatheter VIV replacement was accomplished by the transapical (mitral) and transfemoral venous (tricuspid) approaches. Median postoperative length of stay was five days (range 3-12). No deaths occurred at a mean follow-up of 21 months. NYHA class at follow-up decreased from class IV at baseline to class I or II for all patients. No paravalvular leaks greater than trivial were encountered. Median mean gradient following mitral replacement was 6.5 mmHg (range 6-13 mmHg), and following tricuspid replacement was 4 mmHg. Postoperative complications included hematuria, epistaxis, acute kidney injury, and atrial fibrillation. Transcatheter VIV implantation in the nonaortic position for dysfunctional bioprostheses can be performed safely with favorable clinical outcomes using a balloon expandable TAVR device. doi: 10.1111/jocs.12745 (J Card Surg 2016;31:282-288).

Bioprosthetic mitral valve dysfunction following blunt chest trauma

Bioprosthetic mitral valve dysfunction following blunt chest trauma