Redo Mitral Valve Replacement Surgery Outdoes ViV Over the Long Term

Patients who require treatment to address failed bioprosthetic mitral valves have comparable 30-day outcomes no matter whether it’s a transcatheter valve-in-valve (ViV) procedure or a repeat surgical mitral valve replacement (SMVR), data from two high-volume centers suggest. But at 5 years, redo SMVR offers better survival and hemodynamics, provided that patients are considered suitable for surgery by a multidisciplinary heart team.

The findings follow on the heels of the randomized SURViV trial, released at the American College of Cardiology 2026 Scientific Session. That study focused on younger patients, many of whom had rheumatic heart disease. By 1 year, the ViV group had significantly less all-cause mortality and stroke in comparison to patients who underwent redo surgery. Both therapies led to improvements in symptoms and quality of life.

S. Chris Malaisrie, MD (Northwestern Medicine, Chicago, IL), lead author of the new paper, said that 1 year simply isn’t long enough to gauge how the two options compare. In the PARTNER 3 Mitral Valve-in-Valve (MViV) study, for instance, the mortality rate at 1 year was zero, he pointed out.

“If you’re just looking at short-term follow-up, 1 year or even 2 years, valve-in-valve is going to look better [because it’s] not a reop, it’s a stick in the groin. But when you follow out to 5 years, then you’ll see a survival benefit for surgery,” he told TCTMD.

That said, Malaisrie added, it came as a “big surprise” to see a such clear survival benefit with redo SMVR at 5 years in this study.

It is possible to take precautions to mitigate that gap in mortality between the two interventions, however.

After mitral ViV, “a lot of patients do fine for a while,” said Malaisrie. “But those patients who don’t have a perfect result [with that] should probably get the surgery earlier. I wouldn’t wait for the valve-in-valve to just abjectly fail before we take them to surgery.”

Signs of valve thrombosis or restenosis should inspire action, he explained. “Waiting for advanced structural valve deterioration after a valve-in-valve is not a good strategy.”

Early vs Late Outcomes

Led by Daniel Won, BS (Northwestern Medicine), and published recently in the Annals of Thoracic Surgery, the retrospective analysis included 229 patients without active endocarditis who under underwent redo SMVR (n = 90; mean age 66.0 years) or ViV intervention (n = 139; mean age 68.7 years) at two quaternary care centers between 2004 and 2023.

There were no significant differences in discharge mortality (4.4% vs 2.2%), 30-day mortality (3.3% vs 2.9%) or 30-day readmissions (16.8% vs 14.4%). However, compared with the redo SMVR patients, the ViV patients had shorter postoperative hospital stays (mean 4.5 vs 11.1 days) and less atrial fibrillation (5.8% vs 25.6%; P < 0.001 for both).

While most measures of 30-day MVARC procedural success were similar in the two groups, the ViV patients were less likely to receive prolonged mechanical ventilation (4.3% vs 26.7%) and to develop pneumonia (0.7% vs 11.1%; P < 0.001 for both). Mean mitral gradients were lower immediately after surgery compared with after ViV (5.1 vs 7.8 mm Hg; P < 0.001).

By 5 years, the redo SMVR group continued to have lower mean mitral gradients than the ViV group (5.3 vs 9.8 mm Hg; P < 0.001) and had lower mortality (20.3% vs 40.9%; P = 0.01). There was no difference in the rates of mitral valve reintervention, though there was a trend toward lower cumulative incidence of heart failure with redo SMVR versus ViV (14.3% vs 22.9%; P = 0.27).

Higher STS PROM score was an independent predictor of increased death risk no matter the reintervention type. Within the first year, the choice of ViV versus redo SMVR did not influence mortality. However, beyond 1-year follow-up, redo SMVR was associated with a lower death rate in comparison to ViV (adjusted HR 0.47; 95% CI 0.24-0.93).

“Although multivariable adjustment was performed, residual confounding related to treatment selection cannot be excluded,” the researchers caution. “Therefore, the observed long-term survival difference should be interpreted as associative rather than causal, which partially may be explained by the ability to implant [an] appropriately sized prosthesis during redo SMVR.”

They point out that data from the TVT Registry have similarly highlighted the challenges of ViV in patients with small bioprostheses, for whom higher residual gradients have been linked to worse survival. With redo SMVR, surgeons are able to use larger prostheses.

With ViV procedures, “you’re always going to be restricted by the size of the index surgical valve. We can overcome it with valve fracture, but what we’re noticing is that there is a higher risk of valve thrombosis with valve-in-valve,” Malaisrie said. “And that is possibly what’s leading to valve failure.”

The choice between redo SAVR and ViV can be informed by the patient’s life expectancy, such that those expected to live longer would be best suited to surgery, he said. On the other hand, ViV is of course preferred for patients who have extremely high surgical risk.

Malaisrie suggested that 10-year follow-up from PARTNER 3 MViV, for which he is a principal investigator, will provide further insights.