5-year outcomes following Valve-in-Ring and Valve-in-Valve procedures for failing mitral annuloplasty rings and bioprosthetic valves

Andreas Schäfer (Hamburg)1, D. Gaekel (Hamburg)1, T. J. Demal (Hamburg)1, O. Bhadra (Hamburg)1, I. von der Heide (Hamburg)2, L. E. M. Hannen (Hamburg)2, D. Grundmann (Hamburg)2, L. Voigtländer-Buschmann (Hamburg)2, L. Waldschmidt (Hamburg)2, J. Schirmer (Hamburg)1, S. Pecha (Hamburg)1, N. A. Sörensen (Hamburg)2, S. Blankenberg (Hamburg)2, H. Reichenspurner (Hamburg)1, L. Conradi (Hamburg)1, M. Seiffert (Hamburg)2, N. Schofer (Hamburg)2

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland



In patients at high or prohibitive risk for redo mitral valve surgery, transcatheter mitral valve replacement (TMVR) can be taken into consideration as a less invasive alternative. However, reports of long-term outcomes of valve-in-ring (ViR) and valve-in-valve (ViV) procedures are scarce. We herein report 5-year outcomes following these procedures.



Between 2014 and 2023, 51 consecutive patients received ViR/ViV TMVR at our center. Baseline, periprocedural and 5-year outcome parameters were retrospectively analysed according to M-VARC criteria.



From a total of 51 patients (70.9±13.6 years, STS-Score 3.3±2.3%, LVEF 50±12%), 19 received ViR and 32 ViV TMVR. Follow-up time ranged from 1-71 months. The preferred access shifted from transapical to transseptal over the investigated time (p for trend <0.01). Acute outcomes consisted of a 30-day mortality of 5.9% (3/51, all due to low cardiac output and multi-organ failure) and rehospitalization and stroke rates of 2% (1/51). Bleeding and acute kidney injury occurred in 5.9% (3/51) and 15.7% (8/51) of cases. Technical, device and procedural success were achieved in 84.3% (43/51), 65% (33/51) and 61% (31/51) of patients. Reasons for absence of composite endpoints consisted of 11 cases presenting significant paravalvular leakage (PVL) with consecutive implantation of occluder devices in 9 patients (17.6%), 6 ASD occluder implantations (11.8%) and one conversion to mitral valve surgery (MVS). Majority of PVL occluder implantations were performed for PVL in rigid annuloplasty rings (IMR, Annuloflo; 5/9 cases).

Patient success at 1 year was achieved in 61% (31/51). Overall survival at 5 years was 87.5% after ViR and 83.4% after ViV-TMVR in Kaplan-Meier analysis. During follow-up MVS was necessary in one patient after ViR procedure for increasingly symptomatic LVOT flow acceleration after 12 months and one patient after ViV-TMVR due to increasing transvalvular pressure gradients after 15 months.



Over the last decade a clear shift from the transapical to the transseptal approach was seen in ViV and ViR procedures for failing mitral annuloplasty rings and bioprosthetic valves, further reducing procedural trauma. The herein presented data suggest that these procedures present a reasonable safety and durability profile up to 5 years in this subset of patients at particularly high risk. However, rigid annuloplasty rings are prone to significant residual regurgitation and are frequently in need for additional leakage closure.

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