Arq. Bras. Cardiol. 2020; 115(3): 525-527
Transseptal, Transcatheter Mitral Valve-In-Valve Replacement: Ready for Prime Time Treatment of Bioprosthetic Valve Failure in Brazil?
Dimytri Alexandre Alvim de Siqueira
, Auristela Isabel de Oliveira Ramos, Fausto Feres
Structural Bioprosthetic Valve Deterioration, Failure and Redo Valve Surgery
Bioprosthetic valves are the device of choice for older patients who require left heart valve replacement, and recent data indicate that bioprostheses are also increasingly used in patients less than 65 years of age who undergo aortic or mitral valve surgeries. Although numerous observational studies have shown excellent survival and freedom from valve-related complications, ultimately all bioprosthetic heart valves are prone to fail. The term structural valve deterioration (SVD) includes permanent, irreversible intrinsic changes of the valve (i.e. leaflet tears, calcification, pannus formation or fibrosis); other pathological causes of bioprosthetic valve dysfunction (i.e. thrombosis, endocarditis) are potentially reversible. When significant hemodynamic compromise (severe regurgitation or stenosis) ensues and/or there is a clinical event related to SVD (reintervention, death), the term bioprosthetic valve failure (BVF) is now suggested.
Redo surgical valve replacement is currently indicated for the majority of patients with bioprosthetic SVD. The risk of redo mitral surgery remains much higher than the risk of first mitral valve replacement (MVR). Advanced age, female gender, preoperative NYHA class, reduced left ventricular ejection fraction (LVEF), pulmonary hypertension and the number of prior operations have all been identified as predictors of mortality. Moreover, adhesions from previous surgery substantially increases bleeding complications. In a study with 260 patients enrolled in the European Redo Cardiac Operation Database (RECORD), in-hospital mortality was 9.2% after redo MVR. A high incidence of postoperative complications, such as low cardiac output syndrome (17.3%), need for circulatory support (9.2%), acute renal failure (16.5%) and need for transfusion (25%) was reported. Similarly, a contemporary study from the Society of Thoracic Surgery (STS) with 11,973 patients revealed that mitral reoperation (n=1096) was associated with higher operative mortality (11.1%) in comparison with the first MVR or repair (6.5%). Despite the paucity of data about redo MVR in Brazil, it is well-known that rheumatic heart disease with valvular involvement is the most frequent indication for cardiac valve surgery in young patients. Since BVF is influenced by age – in patients less than 40 years of age, for example, 15-year freedom from reoperation can be as low as 36%-, patients in our country require multiple reinterventions with increasing risks, substantial impact on their quality of life and costs to the healthcare system.
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