RESUMO
Background: Mitral valve diseases are a common medical condition, and surgery is the most used therapeutic approach. The need for less invasive interventions led to the development of transcatheter valve implantation in high-risk patients. However, the treatment to the dysfunctions of these prosthetic valves is still uncertain, and the yield and safety of repeated transcatheter valve implantations remain unclear. Cases summary: A 69-year-old Caucasian woman with three previous mitral valve procedures performed due to rheumatic valve disease (currently with a biological prosthetic mitral valve) and a 76-year-old Latin woman with previous liver transplantation (due to metabolic-associated fatty liver disease) and biological mitral prosthesis due to mitral valve prolapse with severe regurgitation underwent mitral valve-in-valve (ViV) transcatheter implantation at the time of dysfunction of their surgical prostheses. Later, these patients developed prosthetic valve dysfunction and clinical worsening, requiring another invasive procedure. Due to maintained high-risk status and unfavourable clinical conditions for surgery, re-valve-in-valve (re-ViV) was performed. Discussion: Valve-in-valve transcatheter mitral valve implantation was approved in 2017, and, since then, it has been used in several countries, mainly in high-risk patients. Nevertheless, these prosthetic valves may complicate with stenosis or regurgitation, demanding reinterventions. Although there are favourable data for mitral ViV, re-ViV still lacks robust data to support its performance, with only case reports in the literature so far. It is possible that in high-risk patients, there is a greater benefit from re-ViV when compared with the surgical strategy. However, this hypothesis must be studied in future controlled trials.
RESUMO
OBJECTIVES: Concomitant valvular heart valve disease is a frequent finding, with higher morbidity and mortality among patients undergoing redo surgical procedures. Our goal was to report our initial experience with combined transcatheter Inovare bioprosthesis implants for severe valve dysfunction. METHODS: Among 300 transcatheter procedures, a total of 6 patients had concurrent simultaneous transcatheter bioprosthesis implants for severe mitral bioprosthesis failure (valve-in-valve), with a second valve procedure that included native aortic (n = 2) or degenerated bioprostheses in the aortic position (n = 4). During the procedures, all patients were treated with a balloon-expandable Inovare transcatheter valve, using the transapical approach. RESULTS: Patients were highly symptomatic [New York Heart Association (NYHA) functional class IV: 100%], with a mean age of 62 ± 5 years, yielding a mean European System for Cardiac Operative Risk II (EuroSCORE II) of 24.0 ± 10.1%. There was a mean of 1.6 ± 0.4 prior valve operations/patient, with a median time from prior mitral bioprosthesis surgery of 13.0 (9.2-20.0) years. Device success was 100% according to the Mitral Valve Academic Research Consortium and the Valve Academic Research Consortium-2 criteria. During the hospital stay, only 1 patient required dialysis, and the median intensive care unit and hospital lengths of stay were 5.0 (3.2-6.7) days and 16.0 (12.2-21.2) days, respectively. No deaths occurred at 30 days; at a median follow-up of 287 (194-437) days, 1 patient died of a non-cardiac cause and the rest of patients were in NYHA functional class I or II, with normofunctioning bioprostheses. CONCLUSIONS: Transcatheter double valve interventions using the Inovare bioprosthesis in this initial series were shown to be a reasonable alternative to redo surgical operations. The short- and mid-term clinical and echocardiographic outcomes demonstrate promising results, although future studies with a larger number of patients and longer follow-up are warranted.