Outcomes After Transcatheter Mitral Valve-in-Valve Replacement in Patients With Degenerated Bioprosthesis: A Single-Center Experience.

BACKGROUND: This study sought to describe a single center's experience with transcatheter mitral valve-in-valve (TM-ViV) implantation. METHODS: Consecutive patients who had TM-ViV due to degenerative biological valve prosthesis at a single center during a 4-year period were identified from a prospectively maintained database. Operative outcomes were assessed both in-hospital and at 30 days. The primary outcome was in-hospital mortality. Secondary outcomes included valve function, functional status, and quality of life at follow-up. RESULTS: Mean (± standard deviation) patient age was 69 ± 12 years and all patients were high risk for redo surgery (STS risk score, 9.6 ± 6.2%). The primary mechanism of bioprosthetic valve failure was stenosis in 7 patients (47%) and regurgitation in 8 patients (53%). Mean duration between mitral valve replacement (MVR) and transcatheter MVR was 89 months (range, 66-72 months). Failed bioprosthetic valves were replaced with Sapien XT (n = 10; 67%), Sapien (n = 4; 26%), or Sapien S3 valves (n = 1; 7%) (all valves manufactured by Edwards Lifesciences). Procedural success was 100%. No intraoperative deaths were recorded. Postimplantation valve hemodynamics was satisfactory, with a significant improvement in mean valvular gradient (Δ = -12 mm Hg; P<.001) and mitral valve area (Δ = 0.9 cm²; P<.01). At 30-day follow-up, no reports of death, disabling stroke, or rehospitalization for cardiac reasons was recorded. Health status scores were available for 11 of the 15 study patients (73%). Except for 1 patient, significant improvements were seen for all components of the health assessment survey. CONCLUSIONS: TM-ViV for failing biological mitral prosthesis can be performed with minimal operative morbidity and acceptable mid-term clinical and hemodynamic outcomes.

Left Ventricular Function Recovery After Transapical TAVR in Patients With Previous Coronary Artery Bypass Graft Surgery.

OBJECTIVE: The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined. METHODS: Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) <50%. The changes in LVEF and valve function at follow-up (1 to 12 months) were analyzed using paired t-tests. RESULTS: Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had a surgical history of CABG. Overall all-cause mortality rates at 30 days, 1 year, and 2 years were similar for both groups (P = 0.59, P = 0.64, P = 0.78). Subgrouping of CABG-TAVR patients (n = 49) identified 24 patients (49%) with LVEF ≥50% vs. 25 (51%) with LVEF <50%. At 1-year follow-up, significant improvements in LVEF (low LVEF group) and valve function for both groups were observed. LVEF ≥50% group (LVEF: ∆: -3%, P = 0.878; aortic valve area [AVA]: ∆: 1.3 cm2, P < 0.001; mean gradient: ∆: -38 mmHg, P < 0.001); LVEF <50% group (LVEF: ∆: 10%, P = 0.01; AVA: ∆: 1.3 cm2, P < 0.001; MG: ∆: -31 mmHg, P < 0.001). CONCLUSIONS: TA-TAVR can be safely performed with acceptable postoperative outcomes in patients with a history of CABG surgery. In those with reduced EF, significant improvements in LV and valve functions are seen at 1-year follow-up.

The Effect of Continuous-Flow Left Ventricular Assist Device Duration on Postoperative Outcomes.

BACKGROUND: This study evaluated the effect of continuous-flow left ventricular assist device (CF-LVAD) duration on postoperative outcomes in heart transplant patients. METHODS: United Network of Organ Sharing heart transplant follow-up data from 2005 to 2015 were obtained. Patients supported by CF-LVADs who subsequently underwent cardiac transplantation were studied. The study population was divided into three groups by CF-LVAD duration of less than 1 year, 1 to 2 years, and more than 2 years. Multivariable Cox regression analysis was used to identify predictors of overall postoperative graft survival. Kaplan-Meier survival functions were used to estimate actuarial survival at 1, 2, and 5 years after transplant. The association between CF-LVAD duration and postoperative acute rejection episodes before and after hospital discharge was assessed. RESULTS: Of 21,336 recipients, 4,382 had CF-LVADs before cardiac transplantation: 2,603 (59.4%) had CF-LVADs for less than 1 year, 1,178 (26.9%) for 1 to 2 years, and 601 (13.7%) for more than 2 years. Donor age, high body mass index, dialysis dependence, and poor functional status at transplant were significant predictors of poor posttransplant graft survival. CF-LVAD duration was associated with increased incidence of acute rejection before hospital discharge (odds ratio, 1.14; 95% confidence interval, 1.02 to 1.28; p = 0.019). Duration was not related to acute rejection episodes after discharge. There was no difference in survival among patients with increasing time durations (hazard ratio, 1.01; 95% CI, 0.89 to 1.15; p = 0.824). Graft survival at 1, 2, and 5 years among patient groups was not significantly different (p = 0.824 by log-rank test) CONCLUSIONS: Duration of CF-LVAD support does not affect posttransplant graft survival. Longer duration of support increases acute rejection episodes; however, this may not translate into diminished survival.