Valve‐in‐Valve Transcatheter Mitral Valve Replacement Versus Redo Surgical Mitral Valve Replacement: Meta‐Analysis of Early and Late Outcomes

Background Bioprosthetic mitral valve degeneration is traditionally treated with redo surgical mitral valve replacement (redo‐SMVR), but valve‐in‐valve transcatheter mitral valve replacement (ViV‐TMVR) offers a less invasive alternative. Methods Systematic review and meta‐analysis of studies comparing ViV‐TMVR and redo‐SMVR. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane databases (inception to September 2025) were searched. Meta‐analyses were conducted with random‐effects models to assess patient‐relevant outcomes; Kaplan–Meier‐derived time‐to‐event data were pooled to assess late outcomes. Results Thirteen observational studies met our eligibility criteria, including 15 941 patients (ViV‐TMVR: 5465; redo‐SMVR: 10476). In comparison with redo‐SMVR, ViV‐TMVR was associated with lower risk of in‐hospital mortality (risk ratio [RR], 0.72 [95% CI, 0.57–0.90]; P =0.004), stroke (RR, 0.49 [95% CI, 0.29–0.83]; P =0.008), bleeding (RR, 0.43 [95% CI, 0.20–0.94]; P =0.035), acute kidney injury (RR, 0.57 [95% CI, 0.42–0.77]; P <0.001), permanent pacemaker implantation (RR, 0.30 [95% CI, 0.19–0.49]; P <0.001), and shorter hospital length of stay (mean difference,−5.09 days [95% CI, −6.56 to −3.63]; P <0.001). There was no statistically significant difference between the groups in terms of 5‐year survival (hazard ratio [HR], 0.92 [95% CI, 0.81–1.05]; P =0.256); however, the landmark analysis revealed that ViV‐TMVR was associated with lower risk of death in the initial 6 months (HR, 0.69 [95% CI, 0.58–0.83]; P <0.001) but a higher risk beyond 6 months (HR, 1.47 [95% CI, 1.20–1.79]; P <0.001). Conclusions In patients amenable to ViV‐TMVR, this procedure shows a lower initial risk of death and complications, but higher mortality after 6 months in comparison with redo‐SMVR. These findings highlight the importance of striking a balance between upfront surgical risk and estimated life expectancy when selecting interventions.