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 valve-in-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.

/pdf/mitral-valve-in-valve-and-valve-in-ring-tips-tricks-and-3kwmlr45xh.pdf

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

Background Transcatheter mitral valve-in-valve (TMVIV) procedure with aortic transcatheter heart valves has recently become a less invasive alternative for patients with mitral bioprosthetic dysfunction. This study reports the initial experience of TMVIV implantation using the J-Valve System (JieCheng Medical Technology Corporation Ltd., Suzhou, China). Methods A retrospective observational multicenter study was conducted to evaluate the short-term outcomes of TMVIV. In total, 26 consecutive patients with symptomatic bioprosthetic failure at eight hospitals underwent TMVIV using the J-Valve System between May 2019 and June 2021. Procedural results and clinical outcomes were analyzed using the Mitral Valve Academic Research Consortium criteria. Results The mean age was 75.3 ± 7.1 years and 69.2% of patients were female. The mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 12.3 ± 8.3%. The technical success rate was 96.2%. Nine of the 26 patients (34.6%) were implanted with a J-Valve of a size equal to the internal diameters of the deteriorated prostheses. At the 30-day and 1-year follow-ups, all-cause mortality was 3.8 and 16.0% and the stroke rates were 0 and 12.0%, respectively. Device-related mortality was 0% and the mean mitral valve gradient was 6.4 ± 2.7 mm Hg. No patient experienced device embolization, left ventricular outflow tract obstruction, or mitral valve reintervention. Postprocedural mitral regurgitation was none or trace in all the patients. All the patients were in the New York Heart Association (NYHA) class ≤ II at the last follow-up. Conclusion: Transcatheter implantation of the J-Valve System in high-risk patients with mitral bioprosthetic dysfunction was found to be a reasonable alternative and associated with good short-term outcomes.

https://www.frontiersin.org/articles/10.3389/fcvm.2021.783507/pdf

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

A 32-year-old, 11-week pregnant African woman with known rheumatic heart disease presented to the emergency department with worsening shortness of breath on exertion. She had undergone a double bioprosthetic valve replacement and left atrial appendage resection 8 years prior for severe mitral stenosis, moderate mitral regurgitation and moderate aortic regurgitation. A transo-oesophageal echocardiography at this presentation confirmed a morphologically calcified and stenosed mitral bioprosthesis, with moderate stenosis of her aortic bioprosthesis. Her multidisciplinary team, including cardiologists, cardiothoracic surgeons and obstetricians, came to a consensus decision to proceed with a transseptal transcatheter valve implantation within the mitral valve prosthesis (valve-in-valve implantation). Transthoracic echocardiography performed 2 months post procedure showed satisfactory mitral valve gradients and at 30 weeks' gestation, she successfully delivered her fifth child. 2 years later, the valve in valve complex is still functioning well.

https://casereports.bmj.com/content/bmjcr/14/11/e244270.full.pdf

Mitral valve-in-valve implantation during pregnancy.

Computed tomography reference dimensions for identification of stented surgical mitral bioprostheses valve size.

Role of Cardiac Computed Tomography in Planning Transcatheter Mitral Valve Replacement (TMVR).

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