Transcatheter valve-in-valve or valve-in-ring mitral valve implantation in young women contemplating pregnancy

Background Transcatheter mitral valve implantation (TMVI) is emerging as an alternative to surgical mitral valve replacement (SMVR) in selected high-risk patients. It may avoid redo-biological SMVR and delay definitive mechanical SMVR in young women wishing for pregnancy and suffering from failure of mitral bioprosthesis or annuloplasty. Purpose To evaluate the feasibility, safety and outcomes of TMVI in this specific population. Methods From 2013 to 2018, 12 young women with degenerated mitral bioprostheses (n = 6) and annuloplasties (n = 6), pregnant (n = 1) or wishing for pregnancy (n = 11), were treated with transseptal valve-in-valve or valve-in-ring TMVI, using the Edwards SAPIEN XT/3 valves, and were prospectively followed at 1 month, 6 months, 1 year and yearly thereafter. Results Mean age was 29 ± 5 years and EuroSCORE II 3.2 ± 0.8%. The mode of failure was stenosis in 9 cases and regurgitation in 3. Systolic pulmonary artery pressure was 56 ± 26 mmHg. One TMVI was performed in emergency, in the setting of severe bioprosthesis failure complicated by cardiogenic shock and multiorgan failure. One per-procedure prosthesis atrial embolization occurred and required a conversion to standard surgery. One intra-ventricular obstruction was secondarily observed and lead to an elective SMVR. Median follow-up was 36 (4–51) months. At 6 months/1 year, 83% of the patients were in NYHA classes I/II. Mitral regurgitation was ≤ 1+ in all the cases and mean gradient was 8 ± 2 mmHg. Three patients could achieve 4 uneventful pregnancies. At last follow-up, there was no death and 3 patients underwent definitive mechanical SMVR. Conclusion Valve-in-valve and valve-in-ring TMVIs avoid redo biological SMVR and allow young women carrying through uneventful pregnancies. This strategy delays definitive mechanical SMVR and the drawbacks of anticoagulation and may appear as a promising option in young women contemplating pregnancy.