Pooled Analysis of Valve-in-Valve and Valve-in-Ring Transcatheter Mitral Valve Replacement Using the SAPIEN Valve

Transcatheter mitral valve replacement (TMVR) using the Sapien (Edwards Lifesciences, Irvine, CA) transcatheter heart valve has become the preferred treatment for high-risk patients with failed mitral bioprosthetic valves or prior surgical mitral valve repairs. Differences in anatomy and procedural complexity between valve-in-valve TMVR (ViV-TMVR) and valve-in-ring TMVR (ViR-TMVR) may influence clinical outcomes.

We systematically searched OVID Medline, Embase, SCOPUS, Web of Science, and Cochrane for studies published between 2015 and 2022 comparing ViV-TMVR and ViR-TMVR. The primary end point was 30-day all-cause mortality. Secondary outcomes included in-hospital mortality, stroke, acute kidney injury, major bleeding, reintervention, left ventricular outflow tract obstruction, and device embolization. Random-effects models were used to pool outcomes.

Eight studies including 1947 patients (ViV-TMVR: 1435; ViR-TMVR: 512) were analyzed. Patients undergoing ViV-TMVR were older and had a greater baseline comorbidity burden. No significant differences were observed in 30-day mortality (odds ratio [OR]: 0.70 [95% CI: 0.47-1.05]; I²=0%) or in-hospital mortality (OR: 1.05 [95% CI: 0.34-3.21]; I²=3%). Similarly, stroke, major bleeding, and device embolization did not differ significantly between groups. However, ViV-TMVR was associated with lower rates of left ventricular outflow tract obstruction (OR: 0.30 [95% CI: 0.18-0.51]), reintervention (OR: 0.19 [95% CI: 0.13-0.30]), and acute kidney injury (OR: 0.51 [95% CI: 0.29-0.90]), with no significant heterogeneity.

Compared with ViR-TMVR, ViV-TMVR was associated with lower rates of left ventricular outflow tract obstruction, reintervention, and acute kidney injury, whereas mortality and other major complications were comparable. These findings may inform patient selection and procedural planning for transcatheter mitral valve interventions.