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Nappi et al. Vessel Plus 2021;5:40 https://dx.doi.org/10.20517/2574-1209.2021.06 Page 17 of 20

[24]
Recently, Yoon et al. showed superior midterm outcomes in patients who received TMViV (n = 176)
compared to those who underwent TMViR (n = 72). The authors noted that patients receiving the mitral
valve transcatheter procedure for failure of a ring annuloplasty had higher rates of procedural complications
compared to those who had mitral valve in the valve for failure of degenerated bioprostheses valve with a
technical success of 83.3% vs. 96% (P = 0.001), respectively. Medium-term (1-year) mortality was also higher
in the TMViR group (28.7% vs. 12.6%; P = 0.01). Additionally, mechanical intervention for failed
annuloplasty showed worse outcomes in patients who received TMViR and was independently associated
with all-cause mortality, as noted with multivariate Cox analysis (HR = 2.7; 95%CI: 1.34-5.43; P = 0.005).

The FDA approved the use TMVR in prohibitive/high-risk patients but comparable data for surgical repeat
mitral valve repair or replacement outcomes are also needed to assess its safety and indications, especially in
lower-risk patients. TMViR was shown to have poorer results compared to TMViV or MV surgery.

TMViR or valve in MAC is probably less competitive in specific anatomic configuration and less
appropriate in cases of severe hypertrophic obstructive cardiomyopathy for the higher risk of anterior mitral
leaflet displacement. Post-mitral TMViV/R alcohol septal ablation and good prosthetic valve function
cannot be considered helpful to improve the efficacy of the procedure in cases of critical obstruction
because paravalvular leakage is common.

The use of the future benchmarking to TMViV/R could be limited for the presence of young patients, in
whom the procedure is not indicated for ethical and clinical reasons. Resistance to the use of TMViV/R
among surgeons and cardiologists can be motivated, at least in part, by the fact that the clinical advantage of
TMViV/R therapy has only been shown in observational reports and has never been confirmed in
randomized clinical studies.

The ongoing RCT Mitral Implantation of Transcatheter Valves trial (NCT02370511) can certainly provide
further clarifications; however, no patients have been enrolled for a surgical repeat mitral valve replacement
in this registry.

Data from the literature are unable to reach meaningful conclusions, so more in-depth investigations are
required.

CONCLUSION
This review analyzes different outcomes between percutaneous and surgery approaches for degenerated or
failed previous mitral valve intervention.

Data extracted from different studies and reviews help us establish a valid protocol of choice for patients
who need redo surgery due to the degeneration of a mitral biological valve prosthesis or a previous failed
mitral valve repair. The choice between the two methods of reintervention involves the analysis of different
factors and, as described above, is the result of a careful evaluation of the patient characteristics and
comorbidities, the presence of concomitant aortic valve pathology or coronary artery disease, the type of
previous surgery approach and life expectancy. Recently, different studies have shown, in agreement with
our results, that both procedures, TMViV and TMViR, can present different degrees of residual
insufficiency or residual valve stenosis. According to these results, the only way to guarantee the best clinical
result is the careful choice of the patient to be a candidate for TMViV/ViR or for reoperation [38-40] .