Balloon-expandable versus self-expanding valves in patients with prior surgical mitral valve replacement undergoing transcatheter aortic valve replacement

Abstract

Background: Pre-existing mitral prosthesis raises technical challenges for transcatheter aortic valve replacement (TAVR) but has been scarcely studied. In this work we sought to compare outcomes of patients with previous surgical mitral valve prostheses undergoing TAVR with balloon-expandable valve (BEV) or self-expanding valve (SEV) systems. Methods: Patients from the Spanish TAVR registry with pre-existing surgical mitral prostheses were included in this investigation. The primary endpoints were Valve Academic Research Consortium-3 technical and device success, with analysis according to valve type. Transcatheter heart valve (THV) embolization, mitral valve impingement, THV performance, and pacemaker findings were also assessed. Results: A total of 243 patients were included (37% BEVs, 63% SEVs). Overall technical success was 95.9%. Thirty-day device success was higher in BEV patients (94.4% vs 85.0%, P = 0.036), mainly driven by fewer incidences of moderate residual aortic regurgitation (0% vs 5.9%, P = 0.028) and THV embolization (0% vs 3.9%, P = 0.087). BEV recipients exhibited higher mean transvalvular gradients (10.5 vs 8.1 mm Hg, P = 0.002) and lower rates of permanent pacemaker implantation (5.6% vs 15.7%, P = 0.023). There were no differences in mortality, bleeding, or readmission at 30 days. In the multivariate analysis, a mitroaortic distance of < 7 mm and lack of trans-esophageal echocardiography guidance were associated with increased device failure. Conclusions: In patients with pre-existing MV prostheses, TAVR was safe and effective regardless of the THV type. Nevertheless, the use of BEVs resulted in an increased rate of device success, driven by lesser THV embolization and residual aortic regurgitation.