title: Mitral implant of the Inovare transcatheter heart valve in failed surgical bioprostheses: a novel alternative for valve-in-valve procedures.
abstract: Reoperative procedure for the treatment of a failed mitral bioprosthesis is associated with considerable risk. In some cases, mortality is high and might contraindicate the benefit of the procedure. The minimally invasive valve-in-valve (ViV) transcatheter mitral valve implant offers an alternative less-invasive approach, reducing morbidity and mortality. The objective of this paper was to evaluate the mitral ViV approach using the Braile Inovare prosthesis.
  
  
  
  The transcatheter balloon-expandable Braile Inovare prosthesis was used in 12 cases. Procedures were performed in a hybrid operating room, under fluoroscopic and echocardiographic control. Through left minithoracotomy, the prostheses were implanted through the cardiac apex. Serial echocardiographic and clinical examinations were performed. Follow-up varied from 1 to 30 months.
  
  
  
  A total of 12 transapical mitral ViV procedures were performed. Patients had a mean age of 61.6 ± 9.9 years and 92% were women. Mean logistic EuroSCORE was 20.1%. Successful valve implantation was possible in all cases. In one case, a right lateral thoracotomy was performed for the removal of an embolized prosthesis. There was no operative mortality. Thirty-day mortality was 8.3%. Ejection fraction was preserved after the implant (66.7%; 64.8%; P  = 0.3). The mitral gradient showed a significant reduction (11 mmHg; 6 mmHg; P  < 0.001). Residual mitral regurgitation was not present. There was no left ventricular outflow tract obstruction.
  
  
  
  The mitral ViV implant in a failed bioprosthesis is an effective procedure. This possibility might alter prosthesis selection in the future initial surgical prosthesis selection, favouring bioprostheses. Further large trials should explore its safety.
authors.affiliation: Division of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: Diego Felipe
authors.initials: DF
authors.lastname: Gaia
authors.affiliation: Division of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: Ademir Massarico
authors.initials: AM
authors.lastname: Braz
authors.affiliation: Division of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: Matheus
authors.initials: M
authors.lastname: Simonato
authors.affiliation: Division of Cardiology, University of Washington, Seattle, USA.
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.affiliation: Division of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: João Roberto
authors.initials: JR
authors.lastname: Breda
authors.affiliation: Division of Cardiovascular Surgery, PUC Campinas, Campinas - SP, Brazil.
authors.forename: Gustavo Calado
authors.initials: GC
authors.lastname: Ribeiro
authors.affiliation: Division of Anesthesia, Pain and Intensive Care, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: Carolina Baeta
authors.initials: CB
authors.lastname: Ferreira
authors.affiliation: Division of Cardiology, Department of Interventional Cardiology, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: José Augusto Marcondes
authors.initials: JAM
authors.lastname: Souza
authors.affiliation: Division of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: Enio
authors.initials: E
authors.lastname: Buffolo
authors.affiliation: Division of Cardiovascular Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
authors.forename: José Honório
authors.initials: JH
authors.lastname: Palma
mesh_terms: D000368:Aged; D001705:Bioprosthesis; D006328:Cardiac Catheterization; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve; D011474:Prosthesis Design; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cardiac catheterization; Cardiopulmonary bypass; Mitral valve