Long-Term Survival Advantage of Reoperative Surgical Mitral Valve Replacement Over Transcatheter Mitral Valve-in-Valve: A Multicenter Cohort.

Abstract

Although transcatheter mitral valve-in-valve replacement (mViV) is safe, long-term outcomes compared with reoperative surgical mitral valve replacement (rSMVR) remains unknown. This study compared long-term outcomes between mViV and rSMVR in patients with failing mitral bioprostheses. This retrospective, cohort study analyzed patients undergoing mViV or rSMVR for failing bioprosthetic mitral valves without active endocarditis at 2 quaternary care centers from 2004 to 2023. Primary end points included 30-day Mitral Valve Academic Research Consortium (MVARC) procedural success, 5-year cumulative incidence of death, freedom from reintervention, and cumulative incidence of heart failure. Echocardiographic evaluation of mean mitral valve gradients was assessed at baseline and 5-year follow-up. Of 229 patients (90 rSMVR, 139 mViV; mean age, 66.0 vs 68.7 years), MVARC 30-day outcomes were similar except for higher prolonged ventilation with rSMVR. At 5 years, rSMVR had significantly lower mortality (20.3% vs 40.9%; P = .01) and lower mean (standard deviation) mitral gradients (immediate postprocedure: 5.1 [2.3] mm Hg vs 7.8 [3.0] mm Hg; 5-year: 5.3 [2.0] mm Hg vs 9.8 [5.3] mm Hg; P < .001). Freedom from mitral valve reintervention (5.8% vs 6.1%; P = .97) and cumulative heart failure incidence (14.3% vs 22.9%; P = .17) were similar. Although mViV demonstrated comparable 30-day MVARC outcomes, rSMVR was associated with superior long-term survival and hemodynamic durability among patients deemed appropriate surgical candidates by a multidisciplinary heart team. Treatment decisions should balance short-term risk with long-term outcomes.