Long-Term Survival Advantage of Reoperative Surgical Mitral Valve Replacement Over Transcatheter Mitral Valve-in-Valve: A Multicenter Cohort.

BACKGROUND: Although transcatheter mitral valve-in-valve replacement (mViV) is safe, long-term outcomes compared with reoperative surgical mitral valve replacement (rSMVR) remains unknown. This study compared long-term outcomes between mViV and rSMVR in patients with failing mitral bioprostheses. METHODS: This retrospective, cohort study analyzed patients undergoing mViV or rSMVR for failing bioprosthetic mitral valves without active endocarditis at 2 quaternary care centers from 2004 to 2023. Primary end points included 30-day Mitral Valve Academic Research Consortium (MVARC) procedural success, 5-year cumulative incidence of death, freedom from reintervention, and cumulative incidence of heart failure. Echocardiographic evaluation of mean mitral valve gradients was assessed at baseline and 5-year follow-up. RESULTS: Of 229 patients (90 rSMVR, 139 mViV; mean age, 66.0 vs 68.7 years), MVARC 30-day outcomes were similar except for higher prolonged ventilation with rSMVR. At 5 years, rSMVR had significantly lower mortality (20.3% vs 40.9%; P = .01) and lower mean (standard deviation) mitral gradients (immediate postprocedure: 5.1 [2.3] mm Hg vs 7.8 [3.0] mm Hg; 5-year: 5.3 [2.0] mm Hg vs 9.8 [5.3] mm Hg; P < .001). Freedom from mitral valve reintervention (5.8% vs 6.1%; P = .97) and cumulative heart failure incidence (14.3% vs 22.9%; P = .17) were similar. CONCLUSIONS: Although mViV demonstrated comparable 30-day MVARC outcomes, rSMVR was associated with superior long-term survival and hemodynamic durability among patients deemed appropriate surgical candidates by a multidisciplinary heart team. Treatment decisions should balance short-term risk with long-term outcomes.