Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) and redo surgical aortic valve replacement (SAVR) have comparable mortality rates, investigators reported in the Journal of Thoracic and Cardiovascular Surgery.
The observational, retrospective study used institutional databases to compare postoperative complications, transvalvular gradients, mortality, and heart failure readmissions after redo SAVR vs ViV TAVR (TAVR within a previous SAVR).
The participants had ViV TAVR from 2013 to 2022 or isolated redo SAVR from 2011 to 2022 at the authors’ center. The primary outcome was mortality.
A total of 4200 TAVRs and 2306 isolated SAVRs were conducted. The cohort included 198 patients (median age, 79.5 [74.0-85.0] years; 42.4% women) who received ViV TAVR and 147 patients (median age, 65.0 [58.0-73.0 years]; 34% women) who had isolated redo SAVR. The ViV TAVR group had significantly increased rates of peripheral vascular disease, chronic lung disease, and New York Heart Association Class III or IV heart failure.
Both groups had an operative mortality of 2.0%, although the observed to expected operative mortality in the redo SAVR group was greater vs the ViV TAVR group (1.2 vs 0.32). The participants who had redo SAVR were significantly more likely to have postoperative renal failure that required dialysis and to need transfusion, reoperation for bleeding, and permanent pacemaker insertion. The ViV group had significantly increased mean gradients at 30 days (13.0 [9.0-18.0] vs 8.0 [5.0-13.0], P <.001) and at 1 year (14.0 [10.0-20.0] vs 7.5 [6.0-11.0], P <.001).
The redo SAVR group had a median follow-up of 4.1 (2.3-6.8) years compared with 1.8 (0.9-2.8) years in the ViV TAVR group (P <.001). The 2 groups had comparable Kaplan-Meier survival estimates at 1 year (redo SAVR, 92.47% vs ViV, 91.30%). Survival estimates were significantly greater at 5 years for patients who had redo SAVR (80.78% vs 56.06% for ViV), although 5-year data were not available for most patients in the ViV cohort.
Univariable analysis demonstrated that ViV TAVR was associated with a significantly higher hazard of death vs redo SAVR (hazard ratio [HR], 2.33; 95% CI, 1.48-3.67; P <.001). In the multivariable model, this finding was no longer significant (HR, 1.39; 95% CI, 0.65-2.99; P =.40). Age (P =.02) and chronic dialysis (P <.001) were significantly associated with mortality in the multivariable analysis.
The ViV TAVR group had significantly greater competing-risk cumulative incidence estimates of heart failure readmissions, although this finding is based on data that were only available in a minority of patients in the ViV group at 5 years (ViV, 30.89% vs redo SAVR, 18.26%).
Limitations of the study include the potential for selection bias and residual confounding. In addition, the follow-up is short, especially in the ViV group, and the relatively small sample size may lead to sampling error, which limits generalizability of the results.
“As indications for TAVR expand, particularly in the ViV era, the lifetime management of aortic valve disease, with all potential reinterventions, must be emphasized during decision-making,” wrote the researchers. “This requires a data-driven understanding of outcomes for each valve reintervention option.”
Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Yousef S, Serna-Gallegos D, Iyanna N, et al. Valve-in-valve transcatheter aortic valve replacement versus isolated redo surgical aortic valve replacement. J Thorac Cardiovasc Surg. Published online July 1, 2023. doi: 10.1016/j.jtcvs.2023.06.014