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Echarte-Morales et al. Vessel Plus 2021;5:54 https://dx.doi.org/10.20517/2574-1209.2020.105 Page 9 of 13

[49]
There is a lack of studies comparing transcatheter replacement and repeated surgery. Kamioka et al.
compared clinical and echocardiographic outcomes after surgical redo mitral valve replacement and TMVR.
Sixty-two patients underwent TMVR and 59 underwent redo surgery (MR was the procedural reason in
50% and 55%, respectively). Mean age in the TMVR group was 74.9 years with an STS score of 12.8%, while
the redo surgery group had a lower STS score (8.7%) and younger patients (63.7 years). There was a lower
incidence of major bleeding and atrial arrhythmias and a shortening in days of admission in the TMVR
group. Mortality at one year was similar with both strategies in the entire population (TMVR 11.3% vs. redo
surgery 11.9%), with no differences in residual transvalvular gradient or MR recurrence (TMVR 3.8% vs.
redo surgery 5.6%) [49]

Preprocedural exhaustive evaluation of the anatomy is particularly important before TMVR in order to
select the best access route and the prosthetic valve type and size [50,51] . This includes transthoracic and TEE
to evaluate the underlying mechanism of prior surgical failure and the anatomical characteristics of the
interatrial septum and apex, as well as to discard the existence of atrial thrombosis. Moreover, computed
tomography is mandatory to deeply address the structure or the bioprosthetic valve or the type of
annuloplasty ring and anticipate LVOT obstruction after TMVR. In addition, TEE and fluoroscopy are used
for procedural guidance, and fusion imaging software may further facility device deployment .
[52]

Current evidence suggests that TMVR is an appealing and promising option for patients with failed surgical
bioprosthesis and annuloplasty rings. Nevertheless, there are still important challenges that should be
addressed in the following years, such as the universalization of the transeptal route; the impact of high
transmitral gradient; the role of dedicated transcatheter MV prosthesis; the incidence of LVOT; the need for
concomitant treatment of tricuspid regurgitation, if present; how to improve outcomes of ViR procedure;
[53]
and long-term durability of transcatheter prosthetic valves in mitral position .

Percutaneous mitral paravalvular leak closure
Given the high surgical risk for repeated surgery and not-infrequent recurrence after redo open-heart
procedure, percutaneous closure of PVL is becoming a more common approach . This increasing
[54]
experience is leading to moderate to high rates of success, exceeding 90% in very high-volume institutions,
[55]
[55]
with low incidence of periprocedural complications . Sorajja et al. analyzed 30-day outcomes of 115
patients with PVL (78% MV PVL) undergoing percutaneous closure 70 ± 77 months after the index MVS.
The main clinical indication was HF (93% of patients) and most patients had multiple comorbidities (STS
score 6.9% ± 5.6%). Acute procedural success was achieved in 76% of cases and the Amplatzer Vascular Plug
(AVP) II (Abbott, Santa Clara, CA, USA) was the device most frequently used (84%). The incidence of
mayor adverse clinical events at 30 days was 8.7%. Likewise, Alkhouli et al. assessed in hospital and
[56]
midterm outcomes in 231 patients undergoing PVL closure. Successful percutaneous PVL closure was
achieve in 70% of cases and related to a higher survival at 3-year follow-up compared to patients with
significant residual PVL. A recent series from the same working group compared 195 patients undergoing
percutaneous PVL closure and 186 patients undergoing redo MVS. Even though technical success was
higher in the surgical group (95.5% vs. 70.1%), MAE were less frequent in the percutaneous approach,
including in-hospital mortality (3.1% vs. 8.6%), and reinterventions were similar in both groups at 4-year
follow up (11.4% and 17.2% in the percutaneous and surgical groups, respectively) .
[56]

This kind of procedure is usually technically demanding and, therefore, preimplantation planning and
patient selection play a key role in achieving optimal results. In this regard, 3D imaging is the cornerstone
for procedural planning and guidance . 3D-TEE allows identifying the PVL, evaluating the severity of MR,
[57]
and carrying out a comprehensive examination of the anatomy of the prosthetic valve and the MV annulus