Simard Trevor, Lloyd James, Crestanello Juan, Thaden Jeremy J, Alkhouli Mohamad, Guerrero Mayra, Rihal Charanjit S, Eleid Mackram F
Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
Department of Cardiovascular Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
Catheter Cardiovasc Interv. 2022 Apr;99(5):1659-1665. doi: 10.1002/ccd.30059. Epub 2022 Jan 12.
Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to redo surgical mitral valve replacement (SMVR) in patients with degenerated mitral prostheses, with limited comparative data.
We compared mid-term outcomes in patients with degenerated mitral valve prostheses treated with TMVR or redo SMVR. The primary endpoint was survival at 5 years of follow-up.
From 2014 to 2020, 215 patients presented with degenerated mitral valve prostheses. Of whom 86 (40%) were treated with TMVR (75[87%] valve-in-valve and 11[13%] valve-in-ring), while 129 patients (60%) underwent SMVR. The TMVR cohort was older (p < 0.0001), more symptomatic (p = 0.0003) and had more chronic lung disease (p = 0.02), worse renal function (p = 0.02) and higher right ventricular systolic pressures (p < 0.0001). Thirty-day mortality was lower with TMVR versus SMVR (2.4% vs. 10.2%, OR4.69 [95% CI 1.25-30.5], p = 0.04) with probability of mortality at 1, 2, and 5 years being 14.7% versus 17.5%, 24.5% versus 20.7%, and 49.9% versus 34.0%, respectively. Mode of prosthesis degeneration, baseline hemodynamics, and valve selection did not appreciably impact outcomes.
TMVR for degenerated mitral prostheses is associated with better early survival compared to SMVR despite a greater burden of comorbidities. In contrast, 5 year survival rates appear more favorable with SMVR, which may reflect the lower baseline risk of this population. Clinical, hemodynamic, and echocardiographic follow-up support the mid-term durability of TMVR for degenerated mitral prostheses. Further dedicated studies, however, are required to optimize outcomes in this challenging patient cohort and to navigate the choice of approach for each individual patient.
经导管二尖瓣置换术（TMVR）已成为二尖瓣人工瓣膜退化患者再次手术二尖瓣置换术（SMVR）的一种可行替代方案，但比较数据有限。
我们比较了接受TMVR或再次SMVR治疗的二尖瓣人工瓣膜退化患者的中期结局。主要终点是随访5年时的生存率。
2014年至2020年，215例患者出现二尖瓣人工瓣膜退化。其中86例（40%）接受了TMVR治疗（75例[87%]为瓣中瓣，11例[13%]为瓣中环），而129例患者（60%）接受了SMVR。TMVR队列患者年龄更大（p<0.0001），症状更明显（p=0.0003），慢性肺病更多（p=0.02），肾功能更差（p=0.02），右心室收缩压更高（p<0.0001）。与SMVR相比，TMVR的30天死亡率更低（2.4%对10.2%，OR 4.69[95%CI 1.25-30.5]，p=0.04），1年、2年和5年的死亡概率分别为14.7%对17.5%、24.5%对20.7%和49.9%对34.0%。人工瓣膜退化模式、基线血流动力学和瓣膜选择对结局没有明显影响。
尽管合并症负担更大，但与SMVR相比，TMVR治疗二尖瓣人工瓣膜退化与更好的早期生存率相关。相比之下，SMVR的5年生存率似乎更有利，这可能反映了该人群较低的基线风险。临床、血流动力学和超声心动图随访支持TMVR治疗二尖瓣人工瓣膜退化的中期耐久性。然而，需要进一步的专门研究来优化这一具有挑战性的患者队列的结局，并为每个患者选择合适的治疗方法。
