Is reoperation better than TMVR for patients with failed mitral prostheses?

Redoing surgical mitral valve replacement (SMVR) or undergoing transcatheter mitral valve replacement (TMVR) in patients with failed prostheses results in similar 3-year outcomes, reports a recent study. TMVR, however, initially displays a lower risk of major adverse cardiovascular events (MACE), but this risk increases after 6 months.

The study included Medicare beneficiaries aged ≥65 years who underwent redo SMVR or TMVR for failed mitral prostheses between 2016 and 2020. MACE, including all-cause death, heart failure rehospitalization, stroke, or reintervention, up to 3 years (midterm) was the primary endpoint. The investigators used propensity score-matched analysis.

Of the 4,293 eligible patients, 64 percent had undergone redo SMVR and 36 percent TMVR. Those in the TMVR group tended to be older and have a higher comorbidity burden.

The midterm risk of MACE was similar between the matched cohorts (n=1,317 in each group; adjusted hazard ratio [aHR], 0.92, 95 percent confidence interval [CI], 0.80‒1.04; p=0.1).

In the landmark analysis, however, patients in the TMVR group had a lower risk of MACE in the first 6 months (aHR, 0.75, 95 percent CI, 0.63‒0.88; p<0.001), but this risk significantly increased beyond 6 months (aHR, 1.28, 95 percent CI, 1.04‒1.58; p=0.02). Notably, increasing procedural volume contributed to a reduced risk of midterm MACE following redo SMVR (p=0.001) but not after TMVR (p=0.3).

“These findings highlight the importance of striking a balance between surgical risk, anticipated longevity, and hospital expertise when selecting interventions,” the investigators said.