[Mid-term efficacy evaluation of transcatheter mitral valve "valve-in-valve" replacement with different access approaches for degenerated bioprosthesis at single-center].

Abstract

Objective: To evaluate the mid-term outcomes of transcatheter "valve-in-valve" replacement techniques for biological valve failure using different access approaches. Methods: This study is a retrospective cohort analysis. Clinical data were retrospectively analyzed for 101 patients with biological mitral valve failure who underwent transcatheter balloon-expandable "valve-in-valve" replacement at the Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University between May 2021 and July 2025. There were 35 males and 66 females, with an age of (74.5±6.3) years (range: 55 to 86 years). The transapical group comprised 33 patients (32.7%), while the transvenous group included 68 patients (67.3%). Postoperative outcomes were assessed using catheterization, transesophageal echocardiography, and CT scans, with surgical complications and adverse events recorded. Data comparisons were conducted using independent sample t-tests, χ² tests or Fisher's exact probability method. Results: Among the 101 patients, 22 underwent post-implantation annuloplasty. Annuloplasty was performed on 19 (27.9%) patients in the transvenous group versus 3 (9.1%) in the transapical group, showing a statistically significant difference (χ²=8.471, P=0.031). No statistically significant differences were observed between groups in the incidence of wound infection, stroke, or third-degree atrioventricular block (all P>0.031). However, the acrosternal approach group showed significantly higher rates of postoperative pleural effusion (6.1%(2/33) vs. 0, P=0.040) and postoperative bleeding complications (9.1%(3/33) vs. 0, P=0.012) compared to the transvenous approach group. The peak and mean left atrial pressures in the transvenous femoral group after surgery were (23.9±4.8) mmHg (1 mmHg=0.133 kPa) and (15.8±3.2) mmHg, respectively, which were lower than those in the acrosternal approach group (29.2±6.5) mmHg and (20.4±5.6) mmHg,the differences were statistically significant (t=1.624, P=0.008; t=1.598, P=0.007). The postoperative follow-up period was (18±10) months (range: 1 to 36 months). During follow-up, 15 patients (14.9%, 15/101) died. Five deaths (15.1%, 5/101) occurred in the transapical group, including 3 due to heart failure and 2 due to pulmonary infection. Ten patients (14.7%,10/68) died in the transapical group, including 5 due to heart failure, 3 due to pulmonary infection, and 2 due to cerebrovascular accidents. There were no statistically significant differences in all-cause mortality or major adverse cardiovascular events between the two groups (all P>0.05). Conclusions: Transcatheter "valve-in-valve" mitral valve replacement is a viable clinical option for treating biological mitral valve failure, significantly improving hemodynamic status. Compared to the transapical approach, the transvenous approach resulted in fewer postoperative complications such as pleural effusion and bleeding, as well as shorter hospital stays. The impact of the access route on patients' mid-to long-term outcomes requires further validation.