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. 2021 Mar 16;10(6):e019854.
doi: 10.1161/JAHA.120.019854. Epub 2021 Mar 9.

Reoperative Mitral Surgery Versus Transcatheter Mitral Valve Replacement: A Systematic Review

Aditya Sengupta  1 , Farhang Yazdchi  2 , Sophia L Alexis  1 , Edward Percy  2 , Akash Premkumar  2 , Sameer Hirji  2 , Vinayak N Bapat  3 , Deepak L Bhatt  4 , Tsuyoshi Kaneko  2 , Gilbert H L Tang  1
Affiliations

Reoperative Mitral Surgery Versus Transcatheter Mitral Valve Replacement: A Systematic Review

Aditya Sengupta et al. J Am Heart Assoc. .

Abstract

Bioprosthetic mitral structural valve degeneration and failed mitral valve repair (MVr) have traditionally been treated with reoperative mitral valve surgery. Transcatheter mitral valve-in-valve (MVIV) and valve-in-ring (MVIR) replacement are now feasible, but data comparing these approaches are lacking. We sought to compare the outcomes of (1) reoperative mitral valve replacement (redo-MVR) and MVIV for structural valve degeneration, and (2) reoperative mitral valve repair (redo-MVr) or MVR and MVIR for failed MVr. A literature search of PubMed, Embase, and the Cochrane Library was conducted up to July 31, 2020. Thirty-two studies involving 25 832 patients were included. Redo-MVR was required in ≈35% of patients after index surgery at 10 years, with 5% to 15% 30-day mortality. MVIV resulted in >95% procedural success with 30-day and 1-year mortality of 0% to 8% and 11% to 16%, respectively. Recognized complications included left ventricular outflow tract obstruction (0%-6%), valve migration (0%-9%), and residual regurgitation (0%-6%). Comparisons of redo-MVR and MVIV showed no statistically significant differences in mortality (11.3% versus 11.9% at 1 year, P=0.92), albeit higher rates of major bleeding and arrhythmias with redo-MVR. MVIR resulted in 0% to 34% mortality at 1 year, whereas both redo-MVr and MVR for failed repairs were performed with minimal mortality and durable long-term results. MVIV is therefore a viable alternative to redo-MVR for structural valve degeneration, whereas redo-MVr or redo-MVR is preferred for failed MVr given the suboptimal results with MVIR. However, not all patients will be candidates for MVIV/MVIR because anatomical restrictions may preclude transcatheter options from adequately addressing the underlying pathology.

Keywords: redo mitral valve repair; reoperative mitral valve replacement; transcatheter mitral valve replacement; valve‐in‐ring; valve‐in‐valve.

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Conflict of interest statement

Dr Tang is a physician proctor for Medtronic and a consultant for Abbott Structural Heart, Medtronic and W.L. Gore & Associates. Dr Kaneko is a speaker for Abbott Structural Heart and Baylis Medical, a consultant for 4C Medical, and has served as a proctor and educator for Edwards Lifesciences and Medtronic. Dr Bapat has served as a consultant for Medtronic, Edwards Lifesciences, 4C Medical, and Boston Scientific. Dr Bhatt discloses the following relationships—Advisory Board: Cardax, Cereno Scientific, Elsevier Practice Update Cardiology, Medscape Cardiology, PhaseBio, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSoft; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice‐Chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE‐DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS‐II executive committee funded by CSL Behring), Belvoir Publications (Editor‐in‐Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor‐in‐Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Medtelligence/ReachMD (CME steering committees), Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co‐leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR‐ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol‐Myers Squibb, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site Co‐Investigator: Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, Novo Nordisk, Takeda. The remaining authors have no disclosures to report.

Figures

Figure 1
Figure 1. PRISMA diagram for study selection and identification.
PRISMA flowchart for selection of studies for eventual inclusion in the systematic review. MVIR indicates transcatheter mitral valve‐in‐ring replacement; MVIV, transcatheter mitral valve‐in‐valve replacement; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses; redo‐MVr, reoperative mitral valve repair; and redo‐MVR, reoperative mitral valve replacement.
Figure 2
Figure 2. Thirty‐day mortality following reoperative mitral valve replacement (MVR) for bioprosthetic mitral structural valve degeneration (SVD).
Shown here are the 30‐day mortality rates, in ascending chronological order of year of publication, following redo‐MVR for bioprosthetic mitral SVD among various surgical series. The error bars indicate the 95% CIs. 7 , 8 , 14 , 17 , 18 , 20 , 22 , 23
Figure 3
Figure 3. Thirty‐day and 1‐year mortality following mitral valve‐in‐valve (MVIV) replacement.
Mortality rates at 30 days and 1 year are shown among the various MVIV series evaluated, in descending chronological order of year of publication. The error bars indicate the 95% CIs. 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36
Figure 4
Figure 4. Thirty‐day and 1‐year mortality following mitral valve‐in‐ring (MVIR) replacement.
Mortality rates at 30 days and 1 year are shown among the various MVIR series, in descending chronological order of year of publication. The error bars indicate the 95% CIs. 29 , 30 , 32 , 35 , 36 , 49 , 53
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