Outcomes of transcatheter mitral valve replacement for degenerated bioprostheses, failed annuloplasty rings, and mitral annular calcification

Sung Han Yoon, Brian K. Whisenant, Sabine Bleiziffer, Victoria Delgado, Abhijeet Dhoble, Niklas Schofer, Lena Eschenbach, Eric Bansal, Dale J. Murdoch, Marco Ancona, Tobias Schmidt, Ermela Yzeiraj, Flavien Vincent, Hiroki Niikura, Won Keun Kim, Masahiko Asami, Axel Unbehaun, Sameer Hirji, Buntaro Fujita, Miriam SilaschiGilbert H.L. Tang, Shingo Kuwata, S. Chiu Wong, Antonio H. Frangieh, Colin M. Barker, James E. Davies, Alexander Lauten, Florian Deuschl, Luis Nombela-Franco, Rajiv Rampat, Pedro Felipe Gomes Nicz, Jean Bernard Masson, Harindra C. Wijeysundera, Horst Sievert, Daniel J. Blackman, Enrique Gutierrez-Ibanes, Daisuke Sugiyama, Tarun Chakravarty, David Hildick-Smith, Fabio Sandoli De Brito, Christoph Jensen, Christian Jung, Richard W. Smalling, Martin Arnold, Simon Redwood, Albert Markus Kasel, Francesco Maisano, Hendrik Treede, Stephan M. Ensminger, Saibal Kar, Tsuyoshi Kaneko, Thomas Pilgrim, Paul Sorajja, Eric Van Belle, Bernard D. Prendergast, Vinayak Bapat, Thomas Modine, Joachim Schofer, Christian Frerker, Joerg Kempfert, Guilherme F. Attizzani, Azeem Latib, Ulrich Schaefer, John G. Webb, Jeroen J. Bax, Raj R. Makkar*

*Corresponding author for this work
72 Citations (Scopus)


Aims: We sought to evaluate the outcomes of transcatheter mitral valve replacement (TMVR) for patients with degenerated bioprostheses [valve-in-valve (ViV)], failed annuloplasty rings [valve-in-ring (ViR)], and severe mitral annular calcification [valve-in-mitral annular calcification (ViMAC)]. Methods and results: From the TMVR multicentre registry, procedural and clinical outcomes of ViV, ViR, and ViMAC were compared according to Mitral Valve Academic Research Consortium (MVARC) criteria. A total of 521 patients with mean Society of Thoracic Surgeons score of 9.0± 7.0% underwent TMVR (322 patients with ViV, 141 with ViR, and 58 with ViMAC). Trans-septal access and the Sapien valves were used in 39.5% and 90.0%, respectively. Overall technical success was excellent at 87.1%. However, left ventricular outflow tract obstruction occurred more frequently after ViMAC compared with ViR and ViV (39.7% vs. 5.0% vs. 2.2%; P < 0.001), whereas second valve implantation was more frequent in ViR compared with ViMAC and ViV (12.1% vs. 5.2% vs. 2.5%; P< 0.001). Accordingly, technical success rate was higher after ViV compared with ViR and ViMAC (94.4% vs. 80.9% vs. 62.1%; P< 0.001). Compared with ViMAC and ViV groups, ViR group had more frequent post-procedural mitral regurgitation ≥moderate (18.4% vs. 13.8% vs. 5.6%; P< 0.001) and subsequent paravalvular leak closure (7.8% vs. 0.0% vs. 2.2%; P = 0.006). All-cause mortality was higher after ViMAC compared with ViR and ViV at 30 days (34.5% vs. 9.9% vs. 6.2%; log-rank P<0.001) and 1 year (62.8% vs. 30.6% vs. 14.0%; log-rank P< 0.001). On multivariable analysis, patients with failed annuloplasty rings and severe MAC were at increased risk of mortality after TMVR [ViR vs. ViV, hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.27-3.12; P= 0.003; ViMAC vs. ViV, HR 5.29, 95% CI 3.29-8.51; P < 0.001]. Conclusion: The TMVR provided excellent outcomes for patients with degenerated bioprostheses despite high surgical risk. However, ViR and ViMAC were associated with higher rates of adverse events and mid-term mortality compared with ViV.

Original languageEnglish
JournalEuropean Heart Journal
Issue number5
Pages (from-to)441-451
Number of pages11
Publication statusPublished - 2019


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