TMVR Studied for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings

August 21, 2017—Findings from an evaluation of the outcomes of transcatheter mitral valve replacement (TMVR) in patients with failed mitral bioprosthetic valves (valve-in-valve, ViV) and annuloplasty rings (valve-in-ring, ViR) were published by Sung-Han Yoon, MD, et al in Journal of the American College of Cardiology (JACC; 2017;70:1121–1131).

The investigators used data from the TMVR multicenter registry to compare the procedural and clinical outcomes of mitral ViV and ViR according to Mitral Valve Academic Research Consortium criteria.

As summarized in JACC, a total of 248 patients with a mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and a balloon-expandable valve were used in 33.1% and 89.9% of patients, respectively. Seventy-two patients undergoing ViR had lower left ventricular ejection fraction compared with 176 patients undergoing ViV (45.6 ± 17.4% vs 55.3 ± 11.1%; P < .001).

Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, the ViR group had lower technical success compared with the ViV group (83.3% vs 96%; P = .001) because of more frequent second valve implantation (11.1% vs 2.8%; P = .008), and lower device success (76.4% vs 89.2%; P = .009) because of more frequent reintervention (16.7% vs 7.4%; P = .03).

The investigators reported that mean mitral valve gradients were similar between groups (6.4 ± 2.3 mm Hg vs 5.8 ± 2.7 mm Hg; P = .17), whereas the ViR group had more frequent postprocedural moderate-or-higher mitral regurgitation (19.4% vs 6.8%; P = .003).

Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs 2.3%; P = .03), acute kidney injury (11.1% vs 4%; P = .03), and subsequent lower procedural success (58.3% vs 79.5%; P = .001) than compared with the ViV group.

The 1-year, all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs 12.6%; log-rank test; P = .01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.7; 95% confidence interval: 1.34–5.43; P = .005).

The TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and midterm mortality compared with mitral ViV, concluded the investigators in JACC.