NEW ORLEANS — In a clinical trial comparing repeat mitral valve replacement surgery with a transcatheter valve-in-valve approach for dysfunctional bioprosthetic mitral valves, results linked the less invasive technique with a lower rate for death or stroke after 1 year.

“The difference emerged early in the postoperative period,” said Dimytri Siqueira, MD, PhD, an interventional cardiologist at the Dante Pazzanese Institute for Cardiology in Sao Paulo, Brazil.

Siqueira presented results of the SURViV trial at American College of Cardiology (ACC) Scientific Session 2026.

“In the subanalysis, the difference was significant across key subgroups,” Siqueira said during a late-breaking clinical trials session. “This included patients with pulmonary artery hypertension and multiple prior cardiac surgeries and different surgical risk profiles.”

SURViV, Siqueira said, is the first prospective clinical trial to compare the two procedures head-to-head. “Transcatheter mitral valve-in-valve has emerged as a less-invasive therapy for select high-risk patients,” he said. “Yet until now no trial has directly compared these two strategies.”

The trial enrolled 150 patients with mitral bioprosthetic valve dysfunction between February 2020 and November 2023 and randomized them to redo surgery or transcatheter mitral valve-in-valve. The procedures were done at seven referral centers in Brazil.

Trial Results

The primary composite endpoint of all-cause death and disabling stroke at 1 year was 20.8% for the surgery group and 5.3% for those who underwent valve-in-valve repair (P = .005), Siqueira said.

The subgroup analysis evaluated patients according to a number of characteristics, ranging from age to previous surgeries to tricuspid regurgitation status. In all categories, the hazard ratios favored the valve-in-valve procedure, he said.

Clinical adverse events at 30 days were significantly lower for the valve-in-valve group, Siqueira said. Nine patients in the surgical group died, including six from cardiovascular causes, whereas no deaths occurred in the valve-in-valve group a month after the procedure. The median length of hospital stay was 4 days vs 14 days for those who underwent valve-in-valve repair vs surgery (P < .001).

“These early differences likely explain the results observed in the primary endpoint,” Siqueira said.

Echocardiographic outcomes were similar in both groups, though hemodynamic performance was slightly better after redo surgery, according to Siqueira. The average mitral gradient at 12 months was 5.4 mm Hg with redo surgery vs 6.7 mm Hg with valve-in-valve (P = .007). Average prosthetic valve area was larger in the surgery group: 1.7 cm² vs 1.4 cm² (P = .003).

Overall, rehospitalizations were similar between the two groups at 1 year: 16% for valve-in-valve and 11.1% for surgery (P = .39).

“However, rehospitalization for cardiac causes were more frequent after valve-in-valve, including four cases related to leaflet thrombosis, which were managed with anticoagulation therapy,” Siqueira said. In the valve-in-valve group, 16% were hospitalized for cardiac causes within a year vs 2.8% for the redo surgery group (P = .02).

“Importantly, from a patient perspective, both strategies resulted in similar substantial improvements in functional status and quality of life,” he added.

At 1 year, most patients in each group experienced an improvement in a New York Heart Association class from baseline (P = .28). Also, the mean EuroQol-5D visual analog scale was 78.8 and 81.9 compared with 49 and 60.6 at baseline in the valve-in-valve and surgery groups, respectively (P = .83).

Lingering Questions

S. Chris Malaisrie, MD, a cardiac surgeon at Northwestern University in Chicago, questioned why a high percentage of young patients had received bioprosthetic valves at age 45. The average age of study participants was 58 years, with an average of 14 years since their last surgery.

“They should be getting mechanical valves,” he said. “Nevertheless, the question still stands because patients are going to come to us; undoubtedly mitral valves are going to carry a low rate of stroke and death.” 

He also noted the average Society for Thoracic Surgeons mortality score was 3.6 in the overall trial, but the data showed a 13% operative mortality in the redo surgery group, which acted as the control group in the study.

“This calls into question whether or not this was a true control group for this trial,” Malaisrie said.

“We’ll be really interested to see what happens in the long-term follow-up,” he added. “Usually in these cases, we see short-term benefits be overshadowed by long-term benefits. The long-term results are going to be important.”

Siqueira reported having no relevant financial relationships. Malaisrie reported having financial relationships with CryoLife, Medtronic, AtriCure, Edwards LifeSciences, Terumo and Artvion.

Richard Mark Kirkner is a medical journalist based in Philadelphia.