Similar Periprocedural Safety and Efficacy, But Higher 5-Year Mortality Following Valve-in-Valve/Ring TMVR Compared to Re-Do Mitral Valve Surgery

All articles of this category (opens in new window) Background: Long-term data comparing the safety and efficacy of redo-mitral valve (MV) surgery (MVS) and Valve-in-Valve/Ring (ViV/R) transcatheter mitral valve replacement (TMVR) are scarce. Methods: Between 2014 and 2024, 278 patients were treated for failing MV bioprostheses or recurring MV regurgitation after surgical MVS. After exclusion of patients with endocarditis, previous re-do procedures, failing edge-to-edge repair, and concomitant procedures, a total of 110 patients remained for analysis: 55 patients treated by re-do M vs. TMVR, respectively. Periprocedural outcomes and 5-year mortality were retrospectively analyzed. Results: TMVR patients were older (71.47 ± 13.20 vs. 57.67 ± 13.99 years, p < 0.001) and presented with a higher preoperative risk (EuroSCORE II 4.8 ± 2.2 vs. 3.6 ± 2.1, p = 0.002). Coronary artery disease (56.4% vs. 30.9%, p = 0.012) and atrial fibrillation (74.5% vs. 49.1%, p = 0.003) were more common in the TMVR group. Gender distribution (male 52.7% vs. 45.5%, p = 0.567) and left ventricular ejection fraction (50.98 ± 12.23 vs. 54.7 ± 10.4, p = 0.090) showed no difference. The distribution of mitral valve stenosis ( p = 0.683) and regurgitation ( p = 0.090) was similar between both groups. True ID for bioprostheses was similar between groups (25.30 ± 1.97 vs. 26.00 ± 1.62, p = 0.262), and annuloplasty rings were smaller in the TMVR group (30.09 ± 1.73 vs. 31.29 ± 2.71, p = 0.068). Paravalvular leak (PVL = trace 38.2% vs. 5.5%, p < 0.001, PVL ≥ moderate 3.6% vs. 0%, p = 0.495) was more frequent in TMVR, and the postoperative mean transvalvular pressure gradient was higher (7.33 ± 2.62 vs. 6.02 ± 2.50 mmHg, p = 0.010). Permanent pacemaker implantation (PPI; 1.8% vs. 16.4%, p = 0.016) and acute kidney injury (AKI) rates (14.5% vs. 33.3%, p = 0.026) were lower in the TMVR group. In-hospital- (TMVR 3.6% vs. 0.0%, p = 0.495) and 30-day mortality (TMVR 5.5% vs. 0%, p = 0.243) were similar. Five-year mortality was significantly higher following TMVR (35.6% vs. 3.6%, p = 0.002). Reasons for death during follow-up in the TMVR group included LVOT obstruction (2/55), heart failure (1/55), gastrointestinal bleeding (1/55), pneumonia (2/55), and sepsis (1/55). Conclusion: Redo SMVR and TMVR present similarly high perioperative clinical safety and efficacy. Rates of PVL and mean transvalvular pressure gradients were higher after TMVR, while redo M vs. presented higher rates of PPI and AKI. Higher 5-year mortality following TMVR is likely attributable to higher patient age and comorbidity burden. Patient selection should therefore be performed through heart team discussion for individual patient treatment. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany