Valve-in-Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement: Meta-Analysis of Early and Late Outcomes.

BACKGROUND

Bioprosthetic mitral valve degeneration is traditionally treated with redo surgical mitral valve replacement (redo-SMVR), but valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) offers a less invasive alternative.

METHODS

Systematic review and meta-analysis of studies comparing ViV-TMVR and redo-SMVR. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane databases (inception to September 2025) were searched. Meta-analyses were conducted with random-effects models to assess patient-relevant outcomes; Kaplan-Meier-derived time-to-event data were pooled to assess late outcomes.

RESULTS

Thirteen observational studies met our eligibility criteria, including 15 941 patients (ViV-TMVR: 5465; redo-SMVR: 10476). In comparison with redo-SMVR, ViV-TMVR was associated with lower risk of in-hospital mortality (risk ratio [RR], 0.72 [95% CI, 0.57-0.90]; P=0.004), stroke (RR, 0.49 [95% CI, 0.29-0.83]; P=0.008), bleeding (RR, 0.43 [95% CI, 0.20-0.94]; P=0.035), acute kidney injury (RR, 0.57 [95% CI, 0.42-0.77]; P<0.001), permanent pacemaker implantation (RR, 0.30 [95% CI, 0.19-0.49]; P<0.001), and shorter hospital length of stay (mean difference,-5.09 days [95% CI, -6.56 to -3.63]; P<0.001). There was no statistically significant difference between the groups in terms of 5-year survival (hazard ratio [HR], 0.92 [95% CI, 0.81-1.05]; P=0.256); however, the landmark analysis revealed that ViV-TMVR was associated with lower risk of death in the initial 6 months (HR, 0.69 [95% CI, 0.58-0.83]; P<0.001) but a higher risk beyond 6 months (HR, 1.47 [95% CI, 1.20-1.79]; P<0.001).

CONCLUSIONS

In patients amenable to ViV-TMVR, this procedure shows a lower initial risk of death and complications, but higher mortality after 6 months in comparison with redo-SMVR. These findings highlight the importance of striking a balance between upfront surgical risk and estimated life expectancy when selecting interventions.