Mitral valve-in-valve and valve-in-ring: tips, tricks, and outcomes

Abstract

Transcatheter aortic valve implantation is now a mainstay of treatment in patients with aortic stenosis who are considered intermediate, high and prohibitive risk for surgery. Extended use of this innovative platform in treating other conditions has led to its approval in treating degenerated aortic bioprosthesis. Similarly, use of transcatheter devices in treating degenerated mitral bioprosthesis and failed mitral valve repairs with annuloplasty rings has opened a potential alternative to surgery in these patients. Experience in mitral valvein-valve (MVIV) and valve-in-ring (VIR), while still limited, is on the rise. Although similar in many ways to the aortic VIV, it is different with respect to patient selection, planning and procedural steps. Familiarity with the bioprosthetic properties and dimensions can help an operator choose an appropriate transcatheter device and deploy it in an ideal position. Due to greater variability in construction and properties, mitral rings have led to poorer results compared to mitral valve-in-valve. Understanding the properties of mitral rings is critical and has been simplified by us in a stepwise manner. We also describe steps in patient preparation and procedure, which should help operators in performing this procedure. Certain unique complications, such as left ventricular outflow tract obstruction and risk of embolization, are discussed with tips to address these issues. Once these steps are followed, the procedure can be performed with minimal risk and good outcome.

The outcome of mitral repair for degenerative versus ischemic mitral regurgitation using a single complete ring

“…Complete semirigid annuloplasty rings may also have characteristics suitable for future transcatheter valve-in-ring intervention. 26 The current series showed that, for all patients, the degree of recurrent MR increased slowly over time and tended to plateau at about 1+ or mild MR by 5-10 years (Figures 2 and 6A).…”

Transcatheter Mitral Valve-in-Valve Implantation With a New Transcatheter Heart Valve for Bioprosthetic Degeneration

“…Currently, the Sapien 3 (Edwards Lifesciences Incorporation, Irvine, California, USA) is used as the standard THV for most TMVIV interventions with good short-term outcomes ( 7 , 15 ). To avoid embolization, it is important to avoid parallel deployment and achieve conical deployment with an oversizing strategy ( 8 ). Unlike with the Sapien XT (Edwards Lifesciences Incorporation, Irvine, California, USA) ( 16 ), interventionists tend to select the proper Sapien 3 size selection following a slightly oversizing principle for its favorable extensibility.…”

“…In TMVIV, an oversizing strategy is preferred due to the risk of embolization resulting from high gradient pressure between the ventricle and atrium. However, excessive oversizing may be unfavorable, as it leads to under expansion of the transcatheter heart valve (THV) device, which increases the risk of leaflet pin-wheeling, device thrombosis, and decreased durability ( 8 ).…”

Current state of transcatheter mitral valve implantation in bioprosthetic mitral valve and in mitral ring as a treatment approach for failed mitral prosthesis

“…It is not appropriate to perform extreme oversizing, as a significantly underexpanded transcatheter valve may lead to incorrect leaflet coaptation, elevated transvalvular gradient and limited durability. Under-expansion increases the risk of leaflet pin wheeling, possible thrombosis and decreases durability (39).…”

“…An angle of >15° for Sapien S3 (>20° for Sapien S3 Ultra) should raise the concern for post-implant paravalvular leak (PVL) (40). Although CT scans are emerging to be an important imaging modality in these patients, characterization of different bioprosthesis based on CT scans is not standardized and thus, they can only be used as an adjunct to the sizing information in the mitral VIV application (39).…”