Repeat mitral valve repair has been associated with increased mortality. Transcatheter mitral valve repair has surged as an alternative for patients treated with mitral valve-in-valve (MViV), valve-in-ring (MViR), or valve-in-mitral for annular calcification (ViMAC).
Current data from the VIVID and the MAC Global Registry on 30-day evolution in these 3 scenarios show 7.4%, 11.4% and 25% mortality in MViV, MVir and ViMAC respectively. TVT registry outcomes are similar.
At midterm, at 4 years, we only have data from the VIVID registry, showing better survival for MViV patients vs. MVir (62.5% vs. 49.5%, p<0.001). Additionally, MVir patients showed more residual regurgitation, which was associated with worse survival.
The MITRAL Trial had shown better evolution at 2 years in these 3 scenarios.
A 5-year evolution analysis of the Mitral Trial was carried out, a prospective registry using SAPIENS 3 in patients with failed surgical bioprostheses or annuloplasty rings and severe mitral annular calcification. In total, it included 91 patients, 30 receiving MViV, 30 MVir and 31 ViMAC.
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Patients undergoing MViV were mean 76 years of age, 63% were women, had 56% ejection fraction, left ventricle outflow tract 330 mm2 and STS 10.2%; MVir patients were mean 73, 37% women, with 47% ejection fraction, left ventricle outflow tract 440 mm2 and STS 8.7%; and ViMAC patients were man age 75, 71% were women, with 63% ejection fraction and right ventricular outflow tract 60 mm2 and STS 8.6%.
At 5 year followup, mortality was lower in patients undergoing MViV vs. MVir and ViMAC, with rates 21.4%, 65.5% and 67.9% respectively. Functional class I-II were also lower in patients undergoing MViV vs. MVir and ViMAC, with 94.7%, 50% and 55.6% rates respectively. Also, the presence of severe mitral regurgitation was higher in patients with MVir which was associated to higher mortality. Mean gradients were 6.6 mmHg, 5.8 mmHg and 6.7 mmHg, and all groups experienced improved quality of life and y 6-minute walk test outcomes.
Conclusion
MViV, MVir and ViMAC were associated with sustained improvement of heart failure symptoms and quality of life over 5 years. Transcatheter heart valve performance remained stable across groups. MViV patients showed excellent survival at 5 years, while MVir and iMAC patients showed lower survival, consistent with the severity of their underlying condition. Patients with more underlying regurgitation presented higher mortality.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original TItle: 5-Year Prospective Evaluation of Mitral Valve-in-Valve, Valve-in-Ring, and Valve-in-MAC Outcomes. MITRAL Trial Final Results.
Reference: Mayra E. Guerrero, et al. J Am Coll Cardiol Intv 2023;16:2211–2227.
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