Besola Laura, Cheung Anson, Ye Jian, Akodad Myriam, Chatfield Andrew, Sathananthan Gnalini, Moss Robert, Webb John
Division of Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
Ann Cardiothorac Surg. 2021 Sep;10(5):621-629. doi: 10.21037/acs-2021-tviv-19.
Transcatheter mitral valve-in-valve (TMVIV) procedure, either transapical (TA) or trans-septal (TS) has become a valuable alternative to conventional redo surgery in case of failing mitral bioprosthesis with good clinical outcomes. Here we present our fourteen-year institutional experience.
All consecutive patients treated with TMVIV with either TA or TS access at our centre between July 2007 and July 2020 were included. Periprocedural and 30-day follow-up (FU) results are reported and TA and TS data are compared.
Eighty-two patients were included, of those 60 (73.2%) were TA while 22 (26.8%) were TS. Men represented 51.2% of the population with a mean age of 77.3±9.0 years. STS score and EuroSCORE II were 11.4%±6.2% and 11.5%±6.5% respectively. Baseline characteristics of TA and TS groups were comparable. TMVIV was performed at a median time of 9.3 years [interquartile range (IQR), 7.9-12.0 days] from the initial mitral valve surgery. Balloon expandable transcatheter heart valve (THV) prostheses (Edwards LifeSciences Corp., Irvine, CA, USA) were used exclusively. Technical success was 97.6% (96.7% and 100.0% for TA and TS respectively) with two (2.4%) periprocedural death, both in the TA group (P=0.533). We observed four (4.9%) left ventricular outflow tract (LVOT) obstructions with one being hemodynamically significant. Six (7.3%) major bleeding occurred in the TA group, not significantly different from TS group (P=0.279). The median length of stay was 6 days (IQR, 4-12 days, 1.5 7.0 days for TS and TA groups respectively, P=0.001). The overall 30-day mortality rate was 3.7%. We also observed three (3.7%) structural valve deteriorations and in one (1.2%) case the patient required redo mitral surgery at two months. Eighty-seven-point-eight percent of patients were I-II New York Heart Association (NYHA) class. At 30-day FU mean transmitral valve gradient was 7.3±2.7 mmHg and one patient (1.2%) had mitral regurgitation greater than mild. TA and TS groups were comparable.
Our 14-year single-center experience with TMVIV confirms procedural safety and is an effective alternative to redo surgery with comparable results with both TA and TS. With device, technical improvements and increasing operators' experience, TS is the preferred option for TMVIV. However, in some highly selected patient, TA may still play an important role.
经导管二尖瓣瓣中瓣（TMVIV）手术，无论是经心尖（TA）还是经房间隔（TS）入路，在二尖瓣生物瓣功能衰竭的情况下已成为传统再次手术的一种有价值的替代方法，临床效果良好。在此，我们介绍我们14年的机构经验。
纳入2007年7月至2020年7月期间在我们中心接受TA或TS入路TMVIV治疗的所有连续患者。报告围手术期和30天随访（FU）结果，并比较TA和TS数据。
纳入82例患者，其中60例（73.2%）为TA入路，22例（26.8%）为TS入路。男性占总人群的51.2%，平均年龄为77.3±9.0岁。胸外科医师协会（STS）评分和欧洲心脏手术风险评估系统（EuroSCORE）II分别为11.4%±6.2%和11.5%±6.5%。TA组和TS组的基线特征具有可比性。TMVIV在初次二尖瓣手术后的中位时间为9.3年[四分位间距（IQR），7.9 - 12.0天]进行。仅使用球囊扩张式经导管心脏瓣膜（THV）假体（美国加利福尼亚州欧文市爱德华生命科学公司）。技术成功率为97.6%（TA组和TS组分别为96.7%和100.0%），围手术期死亡2例（2.4%），均在TA组（P = 0.533）。我们观察到4例（4.9%）左心室流出道（LVOT）梗阻，其中1例具有血流动力学意义。TA组发生6例（7.3%）大出血，与TS组无显著差异（P = 0.279）。中位住院时间为6天（IQR，4 - 12天，TS组和TA组分别为1.5 - 7.0天，P = 0.001）。总体30天死亡率为3.7%。我们还观察到3例（3.7%）结构性瓣膜退变，1例（1.2%）患者在两个月时需要再次进行二尖瓣手术。87.8%的患者为纽约心脏协会（NYHA）心功能I - II级。在30天随访时，平均二尖瓣跨瓣压差为7.3±2.7 mmHg，1例患者（1.2%）二尖瓣反流大于轻度。TA组和TS组具有可比性。
我们14年单中心TMVIV经验证实了手术安全性，是再次手术的有效替代方法，TA和TS入路的结果相当。随着器械、技术的改进以及术者经验的增加，TS是TMVIV的首选入路。然而，在一些经过严格筛选的患者中，TA可能仍发挥重要作用。
