Transapical Transcatheter Valve-In-Valve Implantation For Failed Mitral Valve Bioprosthesis

Background: The rate of mitral bioprosthesis implantation in clinical practice is increasing. Transcatheter valve-in valve implantation has been described for high risk patients requiring redo valve surgery.Objectives: To report our experience with transapical valve-in valve implantation for failed mitral bioprosthesis.Methods: Since 2010, 10 patients have undergone transapical valve-in-valve implantation for failed bioprosthesis in our center. Aortic valve-in-valve implantation was performed in one of them and mitral valve-in-valve implantation in nine. Mean age was 82 +/- 4 years and 6 were female (67%). Mean time from original mitral valve (MV) replacement to valve-in-valve procedure was 10.5 +/- 3.7 years. Follow-up was completed by all patients with a mean duration of 13 +/- 12 months.Results: Preoperatively, all patients presented with significant mitral regurgitation, two with mitral stenosis due to structural valve failure. All nine patients underwent successful transapical valve-in-valve implantation with an Edwards Sapien (TM) balloon expandable valve. There was no in-hospital mortality. Mean and median hospital duration was 15 +/- 18 and 7 days respectively. Valve implantation was successful in all patients and there were no major complications, except for major femoral access bleeding in one patient. At last follow-up, all patients were alive and in NYHA functional class I or II. Echocardiography follow-up demonstrated that mitral regurgitation was absent or trivial in seven patients and mild in two. At follow-up, peak and mean gradients changed from 26 +/- 4 and 8 +/- 2 at baseline to 16.7 +/- 3 and 7.3 +/- 1.5, respectively.Conclusions: Transcatheter transapical mitral valve-in-valve implantation for failed bioprosthesis is feasible in selected high risk patients. Our early experience with this strategy is encouraging. Larger randomized trials with long-term clinical and echocardiographic follow-up are recommended.