Transcatheter Aortic Valve-in-Valve Implantation versus Redo Surgery: A Contemporary Comparative Analysis

Objectives: Increasing use of aortic bioprostheses will result in growing incidence of structural valve deterioration requiring treatment. As redo surgical aortic valve replacement (SAVR) is associated with elevated perioperative risk, valve-in-valve (ViV) therapy may gain in importance. We compared early and midterm outcomes after ViV with those after conventional redo SAVR.

Methods: In-hospital databases were retrospectively screened for patients ≥60 years treated for failing bioprosthetic aortic valves at our center. Patients with endocarditis and combined procedures were excluded from analysis. Clinical and follow-up characteristics were compared between patients undergoing ViV or redo SAVR according to VARC-2 definitions. Using logistic regression analysis, the comparison of outcome parameters was adjusted for baseline differences between the groups.

Result: Between June 2002 and April 2020, a total of 195 ViV patients and 65 redo SAVR patients met inclusion criteria. Patients in the ViV group were older (77.7 ± 7.0 vs. 71.0 ± 6.6 years, p < 0.001) and had a higher EuroSCORE II (9.8 ± 6.1 vs. 8.0 ± 4.8, p = 0.03). ViV patients less frequently presented with valve sizes ≤21 mm (n = 22 [11.3%] vs. n = 20 [30.8%], p < 0.001).

Adjusted regression analysis did not show statistically significant differences in 30-day (ViV: n = 8 [4.1%], SAVR: n = 2 [3.1%]; p = 0.81) or 6-month mortality (ViV: n = 15/104 [14.4%], SAVR: n = 3/37 [8.1%]; p = 0.64). As ViV patients less frequently experienced acute kidney injury stage II or III (n = 4 [2.1%] vs. n = 9 [13.8%]; OR = 11.5; p = 0.001) and life-threatening bleeding (n = 8 [4.1%] vs. n = 19 [29.2%]; OR = 19.8; p < 0.001), they more frequently reached the VARC-2 endpoint early safety (n = 150 [77.7%] vs. n = 40 [61.5%]; OR = 0.4; p = 0.005). On the other hand, ViV patients less frequently reached the endpoint clinical efficacy (n = 129 [66.2%] vs. n = 55 [84.6%]; OR = 2.4; p = 0.04) and tended to have a lower rate of device success (n = 153 [78.5%] vs. n = 60 [92.3%]; OR = 2.8; p = 0.05), as they showed a higher number of patients with postprocedural transvalvular gradients >20 mm Hg (n = 28 [26.5%] vs. n = 4 [6.2%], OR = 0.2; p = 0.003). Furthermore, ViV patients less frequently experienced pacemaker implantation (PPI; n = 10 [5.2%] vs. n = 12 [18.5%]; OR = 5.4; p = 0.002).

Conclusion: In this single-center cohort, ViV appears preferable to redo SAVR in terms of early safety, whereas SAVR was associated with beneficial postprocedural valve function. To evaluate the long-term durability of ViV prostheses, further studies are needed.

Publication History

Article published online:
19 February 2021