Original article
Adult cardiac
Transapical Transcatheter Valve-in-Valve Implantation for Deteriorated Mitral Valve Bioprostheses

https://doi.org/10.1016/j.athoracsur.2012.08.004Get rights and content

Background

The transcatheter valve-in-valve concept has been described for patients requiring redo valve surgery. We report our experience with transapical mitral valve-in-valve implantation.

Methods

Since 2008, 301 patients were treated with transapical transcatheter valve implantation. Seven of these patients presented with a deteriorated mitral valve bioprosthesis and underwent transapical mitral valve-in-valve implantation. Median age was 79 years. Preoperatively, all patients presented in New York Heart Association functional class III. For risk estimation, The Society of Thoracic Surgeons and European System for Cardiac Operative Risk scores were used and predicted high mortality (mean ± standard error of mean: Society of Thoracic Surgeons mortality, 12.3% ± 2.1%; European System for Cardiac Operative Risk mortality, 58.0% ± 7.0%). Mean follow-up time was 93 ± 29 days, with a total of 21.6 patient-months.

Results

Preoperatively, all patients who had deteriorated bioprostheses presented with severe regurgitation and increased transvalvular pressure gradients (maximal pressure gradient, 23.9 ± 0.9 mm Hg; mean pressure gradient, 11.3 ± 1.0 mm Hg). One patient was identified with mitral valve stenosis (effective orifice area, 0.25 cm2). All patients underwent successful transapical mitral valve-in-valve implantation. Sizes of previously implanted bioprostheses were 27, 29, and 31 mm; Edwards SAPIEN valves at sizes 26 and 29 mm were implanted. Postoperatively, echocardiography revealed excellent hemodynamics with no remaining mitral regurgitation in 5 patients and minimal regurgitation in 2 patients. Transvalvular pressure gradients decreased significantly (maximal pressure gradient, 13.8 ± 2.1 mm Hg; mean pressure gradient 5.7 ± 0.8 mm Hg, p < 0.05). One patient had fatal pneumonia on postoperative day 34. No patient died during further follow-up, and all patients remained in New York Heart Association class I or II.

Conclusions

Our results demonstrate the feasibility of transapical mitral valve-in-valve implantation for treatment of a degenerated bioprosthesis (size range, 27 to 31 mm) using the Edwards SAPIEN valve in sizes 26 and 29 mm.

Section snippets

Patients and Study Design

Since November 2008, 301 patients were treated at our heart center with transapical transcatheter valve implantation. Seven patients within this cohort presented with a deteriorated mitral valve bioprosthesis. Patients' median age was 79 years with an interquartile range from 75 to 81 years. Two patients were male. For risk estimation, The Society of Thoracic Surgeons score and the European System for Cardiac Operative Risk (EuroSCORE) were used. The evaluated Society of Thoracic Surgeons score

Preoperative Data and Medical History

Patients were characterized by incidence of comorbidities and consecutive high procedural risk for conventional reoperative mitral valve surgery. One patient (number 6) presented with a porcelain aorta on top of other reported comorbidities and was most suitable for TAMVI. Active endocarditis was ruled out by laboratory findings and echocardiography in all patients. Table 1 summarizes relevant patient characteristics and reported comorbidities.

Preoperative Echocardiographic Findings

Patients presented with a severely degenerated

Comment

The establishment of catheter-based valve implantation has led to profound changes in the treatment of valvular heart disease in high-risk patients [1]. At the same time, biologic tissue-based prostheses have increasingly outperformed mechanical valves. There is an increased use of these bioprostheses even within the younger patient population [3]. The number of patients with a degenerated bioprosthesis in need for reoperation will rise because of these facts and an increase in life expectancy.

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These authors contributed equally to this work.

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