What is the treatment approach for patients with severe mitral stenosis and a failed bioprosthetic (biological prosthetic) valve using a valve-in-valve procedure?

Valve-in-Valve Procedure for Failed Mitral Bioprosthesis with Stenosis

For severely symptomatic patients with a failed mitral bioprosthesis causing stenosis who are at high or prohibitive surgical risk, transcatheter mitral valve-in-valve replacement is a reasonable treatment option when performed by experienced operators at specialized centers. 1

Treatment Decision Algorithm

Step 1: Risk Stratification and Heart Team Evaluation

• All decisions regarding valve-in-valve versus redo surgery must be made by a multidisciplinary Heart Team including cardiology, cardiothoracic surgery, and valve specialists 1
• Assess surgical risk using clinical judgment and risk scores (STS score, EuroSCORE) 2, 3
• High or prohibitive surgical risk is the primary criterion for considering transcatheter valve-in-valve over redo surgery 1

Step 2: Anatomic Assessment for Hemodynamic Improvement

• Critical consideration: Valve-in-valve should only be performed in patients with larger-sized failed bioprostheses where hemodynamic improvement is anticipated 1
• Smaller prostheses will result in suboptimal hemodynamics because a smaller valve must be placed within the failed bioprosthesis 1
• Use cardiac CT angiography to determine access site (transseptal vs transapical), transcatheter valve size, and landing zone 4, 5
• Evaluate for structural and fluoroscopic characteristics of the failed bioprosthetic valve 1

Step 3: Procedural Approach Selection

Transseptal approach is preferred when anatomically feasible because:

• Less invasive than transapical approach 4
• Associated with faster recovery and more improvement in left ventricular ejection fraction 4
• Possibly lower mortality compared to transapical approach 4

Transapical approach may be necessary based on:

• Anatomic constraints identified on CT imaging 6, 5
• Operator experience and center expertise 5

Step 4: Expected Outcomes

Short-term outcomes from the VIVID Registry (largest registry with 459 patients, ~40% with isolated stenosis):

• 30-day mortality: 7.6% 1
• Major stroke: 1.7% 1
• Functional improvement: 93% of survivors achieved NYHA class I/II 1
• 1-year survival: 83.2% 1

Comparative advantages over redo surgery:

• Similar hemodynamic outcomes 1
• Lower stroke risk 1
• Reduced bleeding risk 1

Critical Contraindications and Limitations

Absolute contraindications:

• Active infective endocarditis 1
• Failed/degenerated transcatheter heart valves (not FDA approved) 1
• Paraprosthetic valve regurgitation as primary indication (not FDA approved) 1

Important caveats:

• No long-term durability data available yet 1
• Requires experienced operators with expertise in structural and fluoroscopic characteristics of failed bioprostheses 1
• Success rate ranges from 70-100% but early experience had learning curve complications 3, 5
• Proper valve positioning is critical—positioning too ventricular can cause stent splaying and embolization 6

Alternative Considerations

For patients who are operable with acceptable surgical risk:

• Redo mitral valve replacement surgery remains the standard approach 1
• Surgery is reasonable even in asymptomatic patients with severe bioprosthetic regurgitation due to risk of sudden clinical deterioration 1

For elderly inoperable patients with degenerative (non-rheumatic) mitral stenosis:

• Very preliminary experience suggests transcatheter valve implantation may be feasible if anatomy is suitable 1
• This represents an emerging option for patients with severely calcified mitral annulus where surgery carries very high risk 1

Post-Procedural Management

• Baseline echocardiography within 30 days post-procedure 1
• Follow-up echocardiography at 1 year and annually thereafter 1
• Monitor for prosthetic dysfunction, valve deterioration, and hemodynamic changes 1
• Anticoagulation management according to valve type and patient factors 7