Surgical Mitral Valve Replacement Research Articles

Outcomes, Cost, and Readmission After Surgical Aortic or Mitral Valve Replacement at Safety-Net and Non–Safety-Net Hospitals

BackgroundSafety-net hospitals provide essential services to vulnerable patients with complex medical and socioeconomic circumstances. We hypothesized that matched patients at safety-net hospitals and non–safety-net hospitals would have comparable outcomes, costs, and readmission rates after isolated surgical aortic valve replacement (AVR) or mitral valve replacement (MVR). MethodsThe National Readmissions Database was queried to identify patients who underwent isolated AVR (n = 109 744) or MVR (n = 31 475) from 2016 to 2018. Safety-net burden was defined as the percentage of patients who were uninsured or insured with Medicaid, with hospitals in the top quartile designated as safety-net hospitals. After propensity score matching, outcomes for AVR and MVR at safety-net hospitals vs non–safety-net hospitals were compared. ResultsOverall, 17 925 AVRs (16%) and 5516 MVRs (18%) were performed at safety-net hospitals, and these patients had higher comorbidity rates, had lower socioeconomic status, and more frequently required urgent surgery. Observed inhospital mortality was similar between safety-net hospitals and non–safety-net hospitals (AVR 2.2% vs 2.1%, P = .4; MVR 4.8% vs 4.3%, P = .1). After matching, rates of inhospital mortality, major morbidity, and readmission were similar; however, safety-net hospitals had longer length of stay after AVR (7 vs 6 days, P = .001) and higher total cost after AVR ($49 015 vs $42 473, P < .001) and MVR ($59 253 vs $52 392, P < .001). ConclusionsIsolated surgical AVR and MVR are both performed at safety-net hospitals with outcomes comparable to those at non–safety-net hospitals, supporting efforts to expand access to these procedures for underserved populations. Investment in care coordination resources to reduce length of stay and curtail cost at safety-net hospitals is warranted.

Percutaneous paravalvular leak closure: a single-centre experience of 54 cases

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Clinically significant paravalvular leak (PVL) occurs in 5-10% of patients undergoing surgical aortic and 5-17% patients undergoing surgical mitral valve replacement and even more often after trancutaneous aortic valve implantation (TAVI). Surgical repair of a PVL is associated with a 30-day mortality of approximately 10%. Percutaneous closure of PVL (pPVLC) has emerged as an alternative to surgical repair. Aim We retrospectively analysed the success rate and clinical outcomes of patients with significant PVL, who were turned down from re-do cardiac surgery, and treated with pPVLC at our tertiary referral centre. Methods Patients who were admitted for pPVLC between 27th of September, 2009 and 21st of April, 2021 were enrolled into the study. 30-day and 1-year mortality rates were assessed. Technically successful pPVLC was defined as stable device position, and minimum 1 grade reduction in PVL severity. Results pPVLC was performed in 54 cases (32 males, 22 females, mean age: 69.5 ± 10.9 yrs). The main indication for closure was heart failure (81%) and haemolysis (19%). The median time since valve surgery was 4.5 yrs (IQR: 0.9-15.2 yrs). Regarding the leaks, 70% (n = 38) were in mitral position (mechanical vale: 33 cases, bioprosthesis: 5 cases) and 30% (n = 16) in aortic position (mechanical valve: 12 cases, bioprosthesis: 2 cases, TAVI: 2 cases). A total of 53 leaks were identified in mitral position (one leak: 25 cases, two leaks: 11 cases, three leaks: 2 cases), and 25 leaks in aortic position (9 cases, 5 cases and two cases resp.). In mitral position 1 device was used in 73% of cases, 2 devices in 21%, and 3 devices in 6%. In aortic position: 62%, 19%, and 19 % resp. Techinal succes was achieved in 49 case (91%). The 30-day mortality was 8%, the 1-year mortality 21%. Conclusions Patients with significant PVL represent an extreme or even prohibitive surgical risk cohort. In these high risk individuals percutaneous PVL offers a safe alternative to surgical PVL repair and appears particularly effective in patients presenting with heart failure or haemolysis.

Mitral paravalvular leak 3D printing from 3D-transesophageal echocardiography - proof of concept

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Higher Education Background Paravalvular leak (PVL) may occur in almost 15% of patients undergoing surgical mitral valve replacement. This complication can cause congestive heart failure and hemolysis. Multimodal imaging including computed tomography (MSCT) and 3D-transesophageal echocardiography (3D-TEE) is essential for assessment of PVLs. 3D-TEE-based 3D-printing might be useful in preprocedural planning of PVL closure for the optimization of transcatether procedures. In contrast to 3D-printing based on MSCT, use of 3D-TEE for segmentation and printing is not standardized. Purpose A proof of concept study to evaluate 3D printing of mitral PVLs using 3D-TEE. Methods A case of a 64-year-old woman with 2 clinically significant PVLs around a mitral prosthetic valve is presented. In 3D-TEE (Philips Epiq) anteromedial defects were visualized (surgical view). Qlab Station was used to export the 3D recording of PVLs with surrounding tissue in cartesian DICOM format. Next Slicer, a free open-source software, was used for segmentation and preparation of a STL (stereolithography) file. The PVL model was printed with Starsys Objet 30 printer using Med620 material. Diameters PVLs were the same in 3D Echocardiography and 3D printed model (12mm and 9mm). Results Printed PVL model and corresponding 3D-TEE image are shown in Figure 1 and Figure 2, respectively. Conclusion(s) Proof of concept study confirms feasibility of using standard 3D-TEE and open source software for preparation of 3D models of anatomically complex mitral PVLs. Further studies to assess cost-effectiveness and clinical applicability of the presented methodology are ongoing. Abstract Figure 1. Abstract Figure 2.

Five-year outcomes of transcatheter mitral valve implantation and redo surgery for mitral prosthesis degeneration.

Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to redo surgical mitral valve replacement (SMVR) in patients with degenerated mitral prostheses, with limited comparative data. We compared mid-term outcomes in patients with degenerated mitral valve prostheses treated with TMVR or redo SMVR. The primary endpoint was survival at 5 years of follow-up. From 2014 to 2020, 215 patients presented with degenerated mitral valve prostheses. Of whom 86 (40%) were treated with TMVR (75[87%] valve-in-valve and 11[13%] valve-in-ring), while 129 patients (60%) underwent SMVR. The TMVR cohort was older (p < 0.0001), more symptomatic (p = 0.0003) and had more chronic lung disease (p = 0.02), worse renal function (p = 0.02) and higher right ventricular systolic pressures (p < 0.0001). Thirty-day mortality was lower with TMVR versus SMVR (2.4% vs. 10.2%, OR4.69 [95% CI 1.25-30.5], p = 0.04) with probability of mortality at 1, 2, and 5 years being 14.7% versus 17.5%, 24.5% versus 20.7%, and 49.9% versus 34.0%, respectively. Mode of prosthesis degeneration, baseline hemodynamics, and valve selection did not appreciably impact outcomes. TMVR for degenerated mitral prostheses is associated with better early survival compared to SMVR despite a greater burden of comorbidities. In contrast, 5 year survival rates appear more favorable with SMVR, which may reflect the lower baseline risk of this population. Clinical, hemodynamic, and echocardiographic follow-up support the mid-term durability of TMVR for degenerated mitral prostheses. Further dedicated studies, however, are required to optimize outcomes in this challenging patient cohort and to navigate the choice of approach for each individual patient.

Infective endocarditis after surgical aortic or mitral valve replacement: A nationwide population-based study

ObjectiveEvidence regarding the incidence of prosthetic valve endocarditis and its association with the use of mechanical or biologic prosthetic valves is limited. MethodsPatients who underwent aortic or mitral valve replacement in the years 2000 to 2017 were identified from Taiwan's National Health Insurance Research Database and grouped according to the type of prosthesis used (mechanical or biologic). Propensity score matching was performed to reduce confounding. ResultsA total of 22,844 patients were included, with 11,950 (52.2%) and 10,934 (47.8%) in the mechanical prosthesis and biologic prosthesis groups, respectively. After matching, each group contained 5441 patients. During follow-up, patients with a biologic prosthesis had a significantly higher risk of infective endocarditis (IE) than those with a mechanical valve (3.4% vs 1.9%; subdistribution hazard ratio, 1.78; 95% CI, 1.40-2.26). Moreover, biologic prostheses were associated with greater risks of all-cause mortality and redo valve surgery, but lesser risks of ischemic stroke, hemorrhagic stroke, major bleeding, and gastrointestinal bleeding. In subgroup analysis, biologic prostheses were consistently associated with a greater risk of IE in all subgroups, specifically single-valve replacement–aortic, single-valve replacement–mitral, double-valve replacement, active IE (IE diagnosed during index hospitalization), any IE (active or old), and not having a history of IE. ConclusionsIn this nationwide population-based retrospective cohort study, biologic prosthesis use was associated with a greater risk of IE during follow-up compared with mechanical valve use. However, mechanical valve use was associated with a greater risk of ischemic stroke and hemorrhagic complications.

National Trends and Outcomes of Surgical Aortic Valve Replacement With Concomitant Mitral Valve Surgery

BackgroundIncidence of multivalvular heart disease is increasing, with aortic stenosis and mitral regurgitation being the most common. Data are limited on outcomes of patients undergoing multivalvular surgery. The purpose of this study was to evaluate contemporary trends and in-hospital outcomes for combined surgical aortic valve replacement (SAVR) and mitral valve repair (MVr) or replacement (MVR). MethodsWe identified patient hospitalizations aged ≥18 years who underwent SAVR + MVr or MVR between 2004 and 2018 using the National Inpatient Sample. Data were weighted to estimate national estimates of the entire US hospitalized population. Exclusion criteria included endocarditis, history of heart transplant or left ventricular assist device, and any other concomitant valve surgery. ResultsBetween January 1, 2004, and December 31, 2018, there were 68,882 weighted admissions for SAVR with concomitant mitral valve surgery. Overall, in-hospital mortality was 8.34% with significantly higher inpatient mortality in SAVR + MVR group compared with SAVR + MVr group (9.91% vs 5.57%, p < 0.001). During the study period, adjusted in-hospital mortality decreased in both SAVR + MVr group (p-trend 0.004) and SAVR + MVR group (p-trend <0.001). Age ≥70 years was associated with higher in-hospital mortality compared to those < 70 years (9.95% vs 6.70%, p < 0.001). ConclusionCombined aortic and mitral valve surgery is associated with a high risk of in-hospital mortality, especially in patients ≥ 70 years of age. Further research is needed to assess the role of transcatheter approaches in the treatment of multivalvular heart disease.

A potential misdiagnosis in the COVID-19 pandemic era: a case report of superimposed thrombosis or tumor recurrence

BackgroundThe clinical manifestations of coronavirus disease 2019 (COVID-19) overlap with those of other disorders, especially cardiovascular disease.Case presentationWe herein describe a 58-year-old woman who presented with syncopal episodes and dyspnea on exertion with a left atrial (LA) mass, scheduled for surgical removal and mitral valve replacement. Nearly 3 months later, the patient developed dyspnea, fever, and a sore throat, resulting in hospital admission with suspected COVID-19. During the diagnostic evaluation, a larger LA mass was detected. The mass seemed to be a COVID-19–induced organized thrombus with prosthetic mitral valve malfunction. Resection was, therefore, planned. An immunohistochemistry study revealed a liposarcoma.ConclusionsThe unusual early recurrence of liposarcomas and the misdiagnosis with COVID-19–induced thrombosis are the hallmark of the present case.

Transcatheter Mitral Edge-to-Edge Repair in Patients with Primary or Secondary Mitral Regurgitation

&#x0D; Four systematic reviews (SRs) and 6 retrospective cohort studies provided evidence for the clinical effectiveness of transcatheter mitral valve repair (TMVR) versus open heart conventional surgical mitral valve repair or replacement (SMVR) in patients with primary or secondary mitral regurgitation (MR). No relevant evidence regarding the cost-effectiveness of TMVR versus SMVR in patients with primary or secondary MR was identified; therefore, no summary can be provided.&#x0D; There was evidence indicating a statistically significant difference in favour of TMVR over SMVR regarding the odds of post-procedure bleeding, need for permanent pacemaker implantation, 30-day readmission, and a shorter duration of hospitalization.&#x0D; There was evidence suggesting a statistically significant difference in favour of SMVR over TMVR regarding the odds of recurrent MR, the need for reoperation, and mortality rate (i.e., during hospitalization, at 1 year, and &gt; 3 years). Also, compared with TMVR, the likelihood of residual MR grade &gt; 2 or freedom from MR grade ≥ 2 or ≥ 3 at 4 years was statistically significantly lower or higher, respectively, with SMVR.&#x0D; Evidence regarding the comparative clinical effectiveness of TMVR versus SMVR concerning stroke, acute kidney injury (AKI), cardiogenic shock, and death during hospitalization was conflicting and inconclusive.&#x0D; There was no evidence of a significant difference between the 2 interventions regarding overall mortality or mortality at 5 years, overall survival, freedom from cardiac death at 4 years, cardiac arrest, acute myocardial infarction (MI), and respiratory or vascular complications.&#x0D; A major limitation of the evidence was that it derives from studies of low or unknown quality and risk of bias, Furthermore, all the findings are confounded by differences in patient selection, which reflect the approved indications for the interventions but prevent a direct comparison between the TMVR and SMVR groups.&#x0D;

National prevalence and outcomes of different mitral valve interventions for mitral regurgitation among patients with cardiogenic shock: an analysis of the national readmission database 2010–2018

Abstract Background Prevalence and outcome data of mitral valve (MV) interventions for severe mitral regurgitation (MR) in the setting of cardiogenic shock (CS) is limited. Purpose Our aim is to study the national prevalence, mortality, and outcomes of three mitral valve interventions (transcatheter mitral valve (MitraClip), surgical mitral valve repair (sMVR), and surgical mitral valve replacement (sMVr)) in patients with severe MR and CS, and how they compare to a non-invasive medical approach to management. Methods Patients with concomitant severe MR and CS were included for the years 2010 - 2018 from the national readmission database. We compared the national prevalence, in hospital mortality, readmission rate, and outcomes of patients who were treated either medically (non-invasive), or underwent an invasive approach with MitraClip, sMVR, or sMVr using one-way ANOVA and logistic regression. Results A total of 106,015 patients (68±13 years, 42% women) with severe MR and CS were identified. Of these, 88,696 (84%) were treated medically, while 607 (0.6%) underwent MitraClip, 4,528 (4%) underwent sMVR, and 12,184 (12%) underwent sMVr. Majority of patients in all four groups had a high Elixhauser comorbidity score of &amp;gt;6. In-hospital mortality rate was 31% in the medical therapy group, 14% and 17% in the sMVR and sMVr groups subsequently, and 26% in the MitraClip group (p&amp;lt;0.001). The median cost of hospitalization was significantly higher in the MitraClip group ($400,087) compared to the other groups (medical=$140,282, sMVR =$290,456, and sMVr =$353,688, p&amp;lt;0.001). Readmission rates were significantly lower in the sMVR (0.7%) and sMVr (1%) groups compared to the medical therapy (4%) and MitraClip (6%) groups (p&amp;lt;0.001). MitraClip was associated with a higher use of Impella (Odds Ratio (OR) 2.6; 95% Confidence Interval (CI) 1.8–3.8, p&amp;lt;0.001), intra-aortic balloon pump (IABP) (OR 3.8; 95% CI 2.9–5.1, p&amp;lt;0.001), and vasopressors (OR 1.6; 95% CI 1.1–1.7, p&amp;lt;0.001) than sMVR or sMVr. Extracorporeal membrane oxygenation (ECMO) use was more common in sMVR (OR 2.9, 95% CI 2.5–3.4, p&amp;lt;0.001) and sMVr (OR 2.0,95% CI 1.8–2.2, p&amp;lt;0.001) than in MitraClip. In terms of complications, MitraClip was associated with a higher rate of vascular complications (OR 4.2; 95% CI 1.4–12.8, p&amp;lt;0.001); while both sMVR and sMVr had higher association with significant post-operative bleeding (OR 2.3; 95% CI 1.9–2.8, p&amp;lt;0.001) and (OR 2.1; 95% CI 1.9–2.4, p&amp;lt;0.001) respectively. Conclusion Majority of patients in this cohort with severe MR and CS were treated either medically or underwent surgical MV replacement. Although MitraClip improved hospital mortality over medical therapy, it was associated with a higher mortality risk, readmission rate, and cost of hospitalization when compared to sMVR and sMVr. Funding Acknowledgement Type of funding sources: None.

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&amp;gt;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&amp;lt;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.

Transcatheter mitral valve-in-valve implantation: a 10-year single center experience

Abstract Background Transcatheter mitral valve-in-valve (TMVIV) appears a reasonable alternative to surgical redo mitral valve replacement in patients with degenerated mitral prosthesis and high surgical risk with favorable early and mid-terms outcomes. Long-term outcomes are limited by high mortality in a comorbid population. Purpose We aimed to evaluate early prosthesis hemodynamic performance and late clinical outcomes following TMVIV. Methods All patients who underwent TMVIV for degenerated surgical mitral bioprostheses from 2011 to 2020 in our center were included. Prospectively collected demographic, clinical, procedural, and imaging variables were analyzed. Clinical and echocardiographic outcomes were defined according to Mitral Valve Academic Research Consortium (MVARC) definitions and assessed at 30-day and at the latest follow-up available. Results A total of 67 patients were included; mean age 76.9±9.6 years, mean STS score 11.0±6.2%, 53.7% male (n=36). Mechanisms of bioprosthetic failure were mitral stenosis (n=32, 47.8%), mitral regurgitation (n=24, 35.8%), and mixed (n=11, 16.4%). Mean time from mitral valve surgery to TMVIV was 10.2±4.3 years. Access was mostly transapical (n=45; 67.2%), followed by transseptal (n=22; 32.8%). Following the first transseptal procedure in 2016; transseptal access accounted for the majority of procedures (22 of 37 cases, 59.4%). Technical success was achieved in 65 patients (97.0%). Mean hospitalization was 9.2±10.0 days; shorter with the transseptal as opposed to the transapical approach (6.3±8.1 days versus 11.0±10.5 days, p=0.001). At 30-day echographic follow-up, mean mitral valve gradient was 7.3±2.7 and 1 patient (1.9%) had mitral regurgitation &amp;gt;mild. At 30-day follow-up, 3 patients had died (4.5%); due to left ventricular outflow tract obstruction (1), heart failure (1), and stroke (1). New pacemakers were required in 2 patients (3.0%) and pacemaker lead dislodgement occurred in 1 patient (1.5%), 4 patients (6.2%) were hospitalized for heart failure. At a median follow-up of 3.8 years [1.7–5.1], 29 patients had died (43.3%), valve thrombosis was found in 6 (8.9%) and endocarditis in 4 patients (6.2%). Mitral valve reintervention was performed in 4 patients (6.2%); redo TMVIV due to valve migration in 1 (1.9%), surgical valve replacement in 1 (1.9%), and delayed redilation with a non-compliant balloon due to underexpansion in 2 patients (3.8%). Conclusion TMVIV is associated with acceptable 30-day mitral valve hemodynamics. Long-term mortality remains high in this high-surgical risk comorbid group. Funding Acknowledgement Type of funding sources: None.

Transcatheter mitral valve replacement for degenerated mitral bioprostheses: a systematic review.

Treatment of degenerated mitral bioprostheses with transcatheter mitral valve-in-valve (MVIV) implantation is increasingly used. The goal of this review was to evaluate the one-year outcomes of this therapy using the most recent evidence. A MEDLINE, Cochrane database and SCOPUS search was performed of published observational studies involving patients undergoing transcatheter MVIV for degenerated bioprosthesis to determine procedural success, thirty-day and one-year survival. A total of 2,684 patients undergoing transcatheter MVIV were identified from five studies with mean age of 73-75 years, 57-63% female and Society for Thoracic Surgery (STS) risk score ranging from 9-13%. Procedural technical success ranged from 94-98%, with 1-3% rates of periprocedural death, 0-2% stroke and 1-5% risk of left ventricular outflow tract (LVOT) obstruction. Thirty-day post-procedure mean mitral prosthetic gradient ranged from 6-7 mmHg and residual mitral regurgitation was mild or less in 96-100% of patients. Thirty-day survival and one-year survival ranged from 93-97% and 83-89% respectively. Transcatheter MVIV is an effective treatment for structural degeneration of biologic mitral valve replacement with low complication rates and favorable one-year outcomes. Accordingly, MVIV should be considered as a reasonable alternative to re-do surgical mitral valve replacement in high risk patients with comorbidities. Further study of long-term outcomes of this treatment is needed.

Conservative, surgical, and percutaneous treatment for mitral regurgitation shortly after acute myocardial infarction.

Severe mitral regurgitation (MR) following acute myocardial infarction (MI) is associated with high mortality rates and has inconclusive recommendations in clinical guidelines. We aimed to report the international experience of patients with secondary MR following acute MI and compare the outcomes of those treated conservatively, surgically, and percutaneously. Retrospective international registry of consecutive patients with at least moderate-to-severe MR following MI treated in 21 centres in North America, Europe, and the Middle East. The registry included patients treated conservatively and those having surgical mitral valve repair or replacement (SMVR) or percutaneous mitral valve repair (PMVR) using edge-to-edge repair. The primary endpoint was in-hospital mortality. A total of 471 patients were included (43% female, age 73 ± 11 years): 205 underwent interventions, of whom 106 were SMVR and 99 PMVR. Patients who underwent mitral valve intervention were in a worse clinical state (Killip class ≥3 in 60% vs. 43%, P < 0.01), but yet had lower in-hospital and 1-year mortality compared with those treated conservatively [11% vs. 27%, P < 0.01 and 16% vs. 35%, P < 0.01; adjusted hazard ratio (HR) 0.28, 95% confidence interval (CI) 0.18-0.46, P < 0.01]. Surgical mitral valve repair or replacement was performed earlier than PMVR [median of 12 days from MI date (interquartile range 5-19) vs. 19 days (10-40), P < 0.01]. The immediate procedural success did not differ between SMVR and PMVR (92% vs. 93%, P = 0.53). However, in-hospital and 1-year mortality rates were significantly higher in SMVR than in PMVR (16% vs. 6%, P = 0.03 and 31% vs. 17%, P = 0.04; adjusted HR 3.75, 95% CI 1.55-9.07, P < 0.01). Early intervention may mitigate the poor prognosis associated with conservative therapy in patients with post-MI MR. Percutaneous mitral valve repair can serve as an alternative for surgery in reducing MR for high-risk patients.

Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve in Valve From the National Inpatient Sample.

BackgroundRedo mitral valve surgery is required in up to one‐third of patients and is associated with significant mortality and morbidity. Valve‐in‐valve transcatheter mitral valve replacement (ViV TMVR) is less invasive and could be considered in those at prohibitive surgical risk. Studies on comparative outcomes of ViV TMVR and redo surgical mitral valve replacement (SMVR) remain limited. Our study aimed to investigate the real‐world outcomes of the above procedures using the National Inpatient Sample database.Methods and ResultsWe analyzed National Inpatient Sample data using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) from September 2015 to December 2018. A total of 495 and 2250 patients underwent redo ViV TMVR and SMVR, respectively. The patients who underwent ViV TMVR were older (77 versus 68 years, P<0.01). Adjusted mortality was higher in the redo SMVR group compared with the ViV TMVR group (7.6% versus <2.8%, P<0.01). Perioperative complications were higher among patients undergoing redo SMVR including blood transfusions (38% versus 7.6%, P<0.01) and acute kidney injury (36.7% versus 13.9%, P<0.01). Cost of care was higher (USD$57 172 versus USD$52 579, P<0.01), length of stay was longer (10 versus 3 days, P<0.01), and discharge to home was lower (20.3% versus 64.6%, P<0.01) in the SMVR group compared with the ViV TMVR group.ConclusionsViV TMVR is associated with lower mortality, periprocedural morbidity, and resource use compared with patients undergoing redo SMVR. ViV TMVR may be a viable option for some patients with mitral prosthesis dysfunction. Studies evaluating long‐term outcomes and durability of ViV TMVR are needed. A patient‐centered approach by the heart team, local institutional expertise, and careful preprocedure planning can help decision‐making about the choice of intervention for the individual patient.

Mitral surgical redo versus transapical transcatheter mitral valve implantation.

Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty. Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria. The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups. Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.

Trends in redo mitral procedure for treating mitral bioprostheses failure: a single center's experience.

BackgroundTranscatheter mitral valve-in-valve implantation (TM-VIV) has emerged as a viable and attractive alternative to surgical mitral valve replacement (SMVR). This study aimed to review a single-center experience with redo mitral procedure for mitral bioprostheses failure over an 8-year period. In addition, it compared procedural safety and early outcomes of various approaches.MethodsBetween January 2013 and January 2021, 79 consecutive patients who underwent redo procedure for mitral bioprostheses failure in our institution were retrospectively reviewed. SMVR and transapical TM-VIV were performed in 54 and 25 patients, respectively. In the SMVR group, 12 patients underwent totally thoracoscopic redo mitral valve replacement (MVR).ResultsThe annual volume of procedures grew continuously during the study period, with the use of totally thoracoscopic redo MVR increasing from 0% in 2012 to 20% in 2019. In 2020, 84.2% of total procedures were performed via the transcatheter approach. Patients in the TM-VIV group were significantly older and had higher scores on the European System for Cardiac Operative Risk Evaluation II (EuroScore II) and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) (P<0.01). The in-hospital mortality for the SMVR group and TM-VIV group was 3.7% (2 patients) and 0, respectively. Compared to the SMVR group, TM-VIV was associated with shorter ventilation time, intensive care unit stay, and postoperative in-hospital stay, and there was less need for blood transfusion. In the subgroup analysis, no significant difference was detected among most perioperative outcomes between the totally thoracoscopy approach group and the TM-VIV group.ConclusionsThere is an increasing number of patients demanding surgical treatments for mitral bioprostheses failure. TM-VIV is playing a significant role due to its scope of application and excellent outcomes.

A novel alternative: transapical transcatheter mitral valve-in-valve implantation using J-Valve for failed bioprosthesis.

BackgroundFailed mitral bioprosthesis has conventionally been treated with redo surgical mitral valve replacement (SMVR). Transcatheter mitral valve-in-valve implantation (TM-VIVI) is emerging as an alternative to SMVR in high-risk patients. We report our experience with transapical TM-VIVI using the J-Valve system.MethodsFrom May 2020 to January 2021, 21 patients with a failed mitral bioprosthesis underwent transapical TM-VIVI without concomitant procedures at Guangdong Provincial People’s hospital. The mean age was 74.62 years. All patients were heavily symptomatic with severe mitral regurgitation and increased trans-prosthetic gradient. The Society of Thoracic Surgeons predicted risk of mortality (STS PROM) and European System for Cardiac Operative Risk Evaluation II (EuroScore II) scores were used and predicted high mortality (STS PROM, 12.91%±9.94%; EuroScore II, 12.04%±10.5%). All the procedures were performed in a hybrid room.ResultsThe success rate was 100% with no conversion to median sternotomy and no intraprocedural death. The mean ventilation time and intensive care unit (ICU) stay were 25±21.44 minutes and 4.14±7.08 days, respectively. No major postoperative complications were observed, except 1 patient suffered pneumonia and required tracheostomy. All patients recovered well. Postoperative echocardiography revealed excellent hemodynamics with no residual mitral regurgitation in 19 patients and mild regurgitation in 2 patients. In a subgroup analysis, no significant differences among procedural and postoperative outcomes were detected in patients with previous aortic-mitral double valve replacement (DVR) compared to other patients.ConclusionsOur results demonstrate the safety and feasibility of transapical TM-VIVI using the J-Valve system, even in patients following DVR.

Towards the age of computer-assisted surgery: how to establish a robotic-assisted mitral surgery program with a last-generation platform

Mitral valve therapy is rapidly evolving. In this context, there is a clear evolution towards the diffusion of minimally invasive techniques for surgical mitral valve replacement or repair, namely in the context of primary mitral regurgitation. The robotic-assisted mitral surgery strategy allows the greatest reduction in surgical trauma to the patients, as well as improved ergonomics and video-assistance for performance of the mitral procedure. We currently observe a rapid diffusion of robotic-assisted mitral valve surgery across Europe, which rightfully forms part of the treatment modalities available to multidisciplinary Mitral Teams. However, the development of a robotic cardiac surgery program should be established maintaining reproducibility and patient safety. Adequate training and preparation are essential to initiate and sustain a robotic-assisted mitral valve surgery program. Herein, we address its main steps: fundamentals, multidisciplinary approach, risk management, team management, development and consolidation. We also present the initial clinical results in our Center, and analyze some learning-curve aspects.

Causes and predictors of mortality after transcatheter mitral valve implantation in patients with severe mitral annulus calcification.

To evaluate the causes and predictors of mortality after valve-in-mitral annulus calcification (MAC) transcatheter mitral valve implantation (TMVI). Conventional surgical mitral valve replacement is associated with a high risk in patients with mitral valve disease associated with severe MAC. In this population, TMVI may be an attractive alternative option. However, its prognostic factors are poorly understood. All patients undergoing valve-in-MAC TMVI from 2013 to 2018 in our center were included. Indication for TMVI relied on the judgment of the local heart team. Patients were followed at 30 days and 1year. A total of 34 patients underwent valve-in-MAC TMVI. The mean age was 79 ± 11 years and 73% of patients were women. Their mean EuroSCORE 2 was 8± 7%. The transseptal approach was used in 79% of patients and a hybrid transatrial in 29%. Balloon expandable transcatheter heart valves were used in all the patients. Technical success was achieved in 76% of the patients. Thirty-day and 1-year all-cause mortality rates were 14.7% and 32.4%, respectively. The main two causes of 1-year mortality were congestive heart failure (8.8%) and infective endocarditis (5.9%). In multivariate analysis, the only predictor of 1-year mortality was the presence of periprothetic mitral regurgitation grade 2 (HR, 5.69; 95%CI, 1.59-27.88, p= 0.032). Early and mid-term mortality remains high after valve-in-MAC TMVI and seems to be associated with the presence of paravalvular mitral regurgitation. However, whether the latter is a prognostic factor or marker remains to be determined to improve clinical outcomes in this high-risk population.

Surgical redo mitral valve replacement in high-risk patients: The real-world experience.

Redo surgical mitral valve replacement (SMVR) remains the gold standard treatment in patients with a history of mitral valve surgery presenting with recurrent mitral valve pathologies. Whilst this procedure is demanding, it is an inevitable intervention for some indications, such as infective endocarditis, thrombosis, or multivalve procedures. In this study, we aim to evaluate our institutional experience with SMVR on a real-life cohort, identifying the factors that contribute to poor surgical outcomes whilst avoiding selection bias. Between March 2012 and November 2020, 58 consecutive high-risk patients underwent a redo SMVR at our institution. The primary endpoints of this study were 30-day and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events. We analyzed and compared the survival in patients undergoing an isolated SMVR and in those that required at least one concomitant procedure. The overall operative, 30-day, and 1-year mortality were 3.4%, 22.4%, and 25.9%, respectively. The mortality in patients undergoing isolated SMVR was significantly lower than in patients requiring concomitant procedures. The multivariable regression model showed that NYHA Class IV, infective endocarditis, and postoperative dialysis were significantly associated with 30-day mortality. Society of Thoracic Surgeons Score, infective endocarditis, concomitant procedures, and mechanical valve implantation appeared to predict long-term mortality. This study illustrates that SMVR after prior mitral valve surgery presents a demanding procedure with high operative risk, significant mortality, and morbidity. Whilst this procedure is inevitable for some indications, a careful patient selection and risk stratification provides acceptable surgical results in this cohort.