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Thorac Cardiovasc Surg
DOI: 10.1055/a-2679-5606
Original Cardiovascular

Three-Year Outcomes Following Mitral Valve-in-Ring and Valve-in-Valve Procedures

Daniel Maldonado Gaekel
1   Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Lara Waldschmidt
2   Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Sebastian Ludwig
2   Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Daniel Kalbacher
2   Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Johannes Schirmer
1   Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Stefan Blankenberg
2   Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Hermann Reichenspurner
1   Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Niklas Schofer   *
2   Department of Cardiology, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
,
Andreas Schaefer   *
1   Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf University Heart and Vascular Center, Hamburg, Hamburg, Germany
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Abstract

Background

In patients at elevated risk for redo mitral valve surgery, transcatheter mitral valve replacement (TMVR) can be taken into consideration as a less invasive alternative. However, long-term outcome data on mitral valve-in-ring (ViR) and valve-in-valve (ViV) procedures are scarce. We herein report the 3-year outcomes following these interventions.

Methods

Between 2014 and 2023, 51 consecutive patients received ViR/ViV TMVR at our center. Baseline, periprocedural, and 3-year outcome parameters were analyzed according to M-VARC criteria.

Results

Among 51 patients (70.9 ± 13.6 years, Society of Thoracic Surgeons (STS) score 3.3 ± 2.3%, left ventricular ejection fraction (LVEF) 50 ± 12%), 19 underwent ViR and 32 underwent ViV TMVR. Follow-up ranged from 1 to 71 months. The 30-day mortality rate was 5.9% (3/51 patients). Over time, access shifted from transapical to transseptal (p for trend <0.01). Rehospitalization, neurological events, and myocardial infarction occurred in 2.0% (1/51 patients), 2.0% (1/51 patients), and 0.0% of the cases, respectively. No structural valve failure was observed. Functional failure was 3.9% of cases due to significant residual mitral valve regurgitation (MR). Most paravalvular leak occluder implantations were performed in ViR patients (6/9, 66.7%; four rigid rings and two semirigid rings). Three-year survival was 87.5% for ViR and 83.4% for ViV, with no difference between groups.

Conclusion

Mitral ViR and ViV procedures demonstrate acceptable safety and clinical efficacy up to 3 years. Rigid annuloplasty rings are associated with an increased risk of significant residual regurgitation. Over the last decade, a clear transition from the transapical to the transseptal access has been observed, further reducing procedural trauma in this high-risk subset of patients.

Keywords

mitral valve surgery - heart valve surgery - reoperation

Authors' Contribution

D.M.G. is the corresponding author, was responsible for data collection, work design, analysis, data interpretation of the work, drafting the work and critical review, final approval of the version to be published, and accountability for the accuracy and integrity of the work. L.W. was responsible for data collection, work design, analysis, and data interpretation of the work. S.L. was responsible for data collection, work design, analysis, and data interpretation of the work. D.K. was responsible for data collection, work design, analysis, data interpretation of the work, critical review, and final approval of the version to be published. J.S. was responsible for data collection, work design, analysis, and data interpretation of the work. S.B. was responsible for data collection, critical review, and final approval of the version to be published. H.R. was responsible for data collection, critical review, and final approval of the version to be published. N.S. was responsible for data collection, work design, analysis, data interpretation of the work, drafting the work and critical review, final approval of the version to be published, and accountability for the accuracy and integrity of the work. A.S. was responsible for data collection, work design, analysis, data interpretation of the work, drafting the work and critical review, final approval of the version to be published, and accountability for the accuracy and integrity of the work.


* These authors contributed equally to this work.




Publication History

Received: 25 March 2025

Accepted: 07 August 2025

Accepted Manuscript online:
11 August 2025

Article published online:
21 August 2025

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