Femoral transcatheter valve-in-valve implantation as alternative strategy for failed aortic bioprostheses: A single-centre experience with long-term follow-up

Rationale and Design of the REPEAT Trial: A Multicenter Randomized Trial Comparing Redo Surgical Aortic Valve Replacement to Valve-in-Valve Transcatheter Aortic Valve Replacement

BACKGROUND

Redo surgical aortic valve replacement (rSAVR) has for long been the therapeutic reference standard for degenerated surgical aortic bioprostheses. Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as an alternative for patients at high surgical risk due to its lower invasiveness. The long-term clinical efficacy of ViV-TAVR in patients at low to intermediate surgical risk remains unknown.

METHODS AND RESULTS

To compare clinical outcomes of redo surgical aortic valve replacement versus ViV-TAVR in low- to intermediate-risk patients with degenerated surgical aortic bioprostheses. REPEAT (Repeat Intervention for Deteriorated Surgical Bioprosthetic Aortic Valves) is an investigator-initiated, international, multicenter, randomized, parallel, open-label trial. A total of 890 patients aged <75 years with a failed surgical aortic bioprosthesis due to structural valve degeneration and low to intermediate surgical risk (ie, Society of Thoracic Surgeons predicted risk of death of <8%) will be randomly assigned in a 1:1 ratio to either redo surgical aortic valve replacement or ViV-TAVR. The primary end point of REPEAT is a composite of all-cause death, stroke (including both disabling and nondisabling), myocardial infarction, and rehospitalization for heart failure or aortic valve reintervention at 5 years, based on Valve Academic Research Consortium-3 definitions. Secondary end points include each of the individual components of the primary composite end point, Valve Academic Research Consortium-3-based conduction disturbances and arrhythmia, Valve Academic Research Consortium-3-based wound and bleeding complications, functional status (ie, 6-minute walk test, Kansas City Cardiomyopathy questionnaire), and treatment costs.

CONCLUSIONS

The REPEAT trial has been designed to test the hypothesis that redo surgical aortic valve replacement is superior to ViV-TAVR regarding clinical outcomes at 5 years in patients with degenerated surgical aortic bioprostheses and low to intermediate surgical risk.

Clinical and hemodynamic outcomes of self-expanding and balloon-expandable valves for valve-in-valve transcatheter aortic valve implantation (ViV-TAVI): An updated systematic review and meta-analysis

Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has emerged as a feasible alternative to reoperative surgery in patients with degenerated surgical bio-prosthesis. However, data regarding the choice of valve type in ViV-TAVI remain inconclusive. This meta-analysis compares the procedural and clinical outcomes of self-expanding (SE) vs. balloon-expandable (BE) valves in ViV-TAVI. MEDLINE and Scopus were queried to identify studies reporting outcomes of ViV-TAVI by SE/BE valve type or comparing outcomes between SE or BE valves for ViV-TAVI. The primary outcome was incidence of all-cause mortality at 30 days. Data were presented as incidence of outcomes, analyzed via random effects model using inverse variance method with 95 % confidence intervals. Further incidence rates of primary and secondary outcomes were presented as subgroups of BE and SE, with comparison in incidence rates between the subgroups made using p-interaction of proportions. 27 studies with 13,182 patients (SE: 7346; BE: 5836) were included. There were no significant differences between the BE vs. SE valves in 30-day mortality (BE 4 % vs. SE 3 %, p = 0.44), 1-year mortality (BE 12 % vs. SE 10 %, p = 0.60), and moderate-to-severe AR at 1 year (BE 1 % vs. SE 3 %, p = 0.36). However, patients with SE valves had higher rates of new permanent pacemaker insertion (BE 4 % vs. SE 9 %, p = 0.0019). There were no significant differences in the incidence of 30-day safety outcomes, including stroke, AKI, coronary obstruction, major bleeding, and major vascular complications. Both BE and SE valve types showed comparable mortality and safety outcomes in ViV-TAVI, except pacemaker insertion, which was higher in SE compared with BE valves.

Transcatheter aortic valve implantation vs. surgery for failed bioprosthesis: a meta-analysis of over 20 000 patients

OBJECTIVES

Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has gained popularity as a less invasive alternative to a redo surgical aortic valve replacement (redo-SAVR); which one is the preferred technique in these cases, however, remains a topic of debate, as the available data refer to retrospective studies with few patients or limited follow-up. The present metanalysis aimed to compare the short-term and long-term outcomes of the two techniques in the setting of a failed surgical bioprosthesis.

METHODS

PubMed, MEDLINE, and Embase were searched on 10 November 2023 yielding 355 results (PROSPERO ID: CRD42023490612), of which 27 were suitable for meta-analysis. The primary outcomes were short-term and long-term all-causes and cardiovascular mortality. Logarithmic risk ratio (Log RR) and mean difference were used for categorical and continuous data, respectively.

RESULTS

Both redo-SAVR and ViV-TAVI exhibited similar procedural and short-term mortality. However, ViV-TAVI demonstrated lower 1-year mortality [RR: 0.74, 95% confidence interval (CI) (0.57-0.96), P = 0.02], acute kidney injury (RR: 0.47, P < 0.001), bleeding (RR: 0.44, P < 0.001), stroke (RR: 0.70, P < 0.05), and new pacemaker implantation (RR: 0.69, P < 0.05). Conversely, redo-SAVR demonstrated more favorable mean postoperative aortic valve gradients [mean difference 2.59, 95% CI (0.86-4.31), P < 0.01].

CONCLUSION

Short-term mortality was similar between the groups, but ViV-TAVI showed better survival at 1 year as well as reduced rates of acute kidney injury, bleeding, stroke, and pacemaker implantation. However, redo-SAVR leads to a better hemodynamic profile. Even if collected data come from retrospective studies, the present results could help to guide the choice of the best approach case-by-case according to the patient's clinical profile.

Redo Surgical Aortic Valve Replacement vs Valve-in-Valve Transcatheter Aortic Valve Replacement for Degenerated Bioprosthetic Valves

BACKGROUND

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is associated with improved perioperative safety compared with redo surgical aortic valve replacement (redo-SAVR), but long-term outcomes remain uncertain. We therefore compare long-term outcomes of ViV-TAVR and redo-SAVR.

METHODS

The study included 1:1 propensity score-matched Medicare beneficiaries with degenerated bioprosthetic valves admitted between September 29, 2011, and December 30, 2020, undergoing either redo-SAVR or ViV-TAVR. Exclusion criteria included endocarditis, other concomitant cardiac surgery, and aortic valve reintervention during the same admission. The primary outcome was 5-year survival. Composite secondary outcomes included major adverse cardiovascular events (30-day operative mortality, stroke, or acute myocardial infarction) and major valve event-free survival (congestive heart failure readmission, endocarditis, or aortic valve reintervention). Time-to-event analyses used Kaplan-Meier analysis and multivariable Cox proportional hazards modeling.

RESULTS

Overall, 4699 patients, including 1775 redo-SAVR and 2924 ViV-TAVR patients, were identified. Redo-SAVR patients were younger (median [interquartile range], 72 [68-77] years vs 79 [73-84] years) with less congestive heart failure (39.6% vs 68.8%) and prior coronary artery bypass grafting (17.9% vs 32.0%; all P < .05). In the propensity score-matched cohorts of 1256 patients each, redo-SAVR had higher major adverse cardiovascular events (17.4% vs 13.1%; P = .003) but better major valve event-free (71 [62-79] months vs 43 [38-47] months; P < .001) and 5-year (62.3% vs 46.7%; P < .001) survival. After stratification by Charlson comorbidity index, the long-term survival benefit persisted in patients of lower (67.6% vs 54.9%; P = .001) and medium or higher risk (55.1% vs 36.7%; P < .001).

CONCLUSIONS

Redo-SAVR may have better long-term survival than ViV-TAVR despite greater perioperative morbidity. Clinical trial data are needed to fully inform clinical decision-making about degenerated bioprosthetic valve reintervention, particularly for patients with reasonable life expectancy.

Enhancing Thromboembolic Risk Prediction in Non-valvular Atrial Fibrillation: The Critical Role of Transesophageal Echocardiography (TEE)

Introduction Atrial fibrillation (AF), the most common cardiac arrhythmia, poses challenges in predicting thromboembolic risk. While the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years (doubled), type 2 diabetes mellitus, previous stroke, transient ischemic attack, or thromboembolism (doubled), vascular disease, age 65-74 years, and sex category) score remains essential, its limitations include failure to identify left atrial (LA) thrombus in some patients. Transesophageal echocardiography (TEE) provides superior detection of LA thrombi and thrombogenic factors compared to transthoracic echocardiography (TTE), improving risk stratification, especially in intermediate-risk groups. Our study highlights the value of TEE in addressing gaps left by clinical scoring systems in certain subgroups of patients. Purpose and methodology This descriptive, prospective study aims to evaluate the role of transthoracic and transesophageal echocardiography in stratifying thromboembolic risk in patients with non-valvular AF. A total of 100 patients, from two hospitals in Morocco, were included. Data were collected through clinical and paraclinical assessments, with echocardiography examining morphological and functional atrial parameters. Results Among the 100 patients, 73% were male, with a mean age of 67 years. AF was permanent in 84.8% of cases, with dyspnea and palpitations being the most common symptoms. Hypertension was the leading underlying cause. Echocardiographic findings showed a correlation between LA enlargement, reduced left atrial appendage (LAA) emptying velocities, and increased thromboembolic risk. In patients with low clinical scores, 30.7% exhibited echocardiographic signs of a thrombogenic environment, while protrusive aortic atheroma was more prevalent in those with higher clinical risk scores. Discussion The findings confirm the utility of echocardiography, particularly transesophageal, in detecting parameters associated with heightened thromboembolic risk, including LAA emptying velocities, spontaneous contrast, and aortic abnormalities. These echocardiographic markers, combined with clinical scores, may enhance the precision of risk stratification and allow for more targeted anticoagulation therapy. Conclusion Atrial fibrillation remains a common and potentially serious arrhythmia. Echocardiography provides valuable information that complements clinical risk stratification, especially for patients at moderate thromboembolic risk. This study highlights the benefit of incorporating echocardiographic parameters into risk assessment to optimize strategies for preventing thromboembolic events in patients with AF.

Long-Term Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation Versus Redo Surgical Aortic Valve Replacement: Meta-Analysis of Kaplan-Meier-Derived Data

Valve-in-valve (ViV) transcatheter aortic valve implantation (ViV-TAVI) in patients with failed bioprostheses arose as an alternative to redo surgical aortic valve replacement (SAVR). To evaluate all-cause mortality in ViV-TAVI versus redo-SAVR, we performed a study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of nonrandomized studies published by August 2023. A total of 16 studies met our eligibility criteria, with a total of 4,373 patients (2,204 patients underwent ViV-TAVI and 2,169 patients underwent redo-SAVR). Pooling all the studies, ViV-TAVI showed a lower risk of all-cause mortality in the first 6 months (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.46 to 0.73, p <0.001), with an HR reversal after this time point favoring redo-SAVR (HR 1.92, 95% CI 1.58 to 2.33, p <0.001). Pooling only the matched populations (which represented 64.6% of the overall population), ViV-TAVI showed a lower risk of all-cause mortality in the first 6 months (HR 0.56, 95% CI 0.43 to 0.73, p <0.001], with a reversal after 6 months favoring redo-SAVR (HR 1.55, 95% CI 1.25 to 1.93, p <0.001). The meta-regression analyses revealed a modulating effect of the following covariates: age, coronary artery disease, history of coronary artery bypass graft surgery, and implanted valves <25 mm. In conclusion, ViV-TAVI is associated with better survival immediately after the procedure than redo-SAVR; however, this primary advantage reverses over time, and redo-SAVR seems to offer better survival at a later stage. Because these results are pooled data from observational studies, they should be interpreted with caution, and randomized controlled trials are warranted.

Redo Surgical Aortic Valve Replacement versus Valve-In-Valve Transcatheter Aortic Valve Implantation: A Systematic Review and Reconstructed Time-To-Event Meta-Analysis

Objective. Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has emerged as a useful alternative intervention to redo-surgical aortic valve replacement (Redo-SVAR) for the treatment of degenerated bioprosthesis valve. However, there is no robust evidence about the long-term outcome of both treatments. The aim of this meta-analysis was to analyze the long-term outcomes of Redo-SVAR versus ViV-TAVI by reconstructing the time-to-event data. Methods. The search strategy consisted of a comprehensive review of relevant studies published between 1 January 2000 and 30 September 2022 in three electronic databases, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE. Relevant studies were retrieved for the analysis. The primary endpoint was the long-term mortality for all death. The comparisons were made by the Cox regression model and by landmark analysis and a fully parametric model. A random-effect method was applied to perform the meta-analysis. Results. Twelve studies fulfilled the eligibility criteria and were included in the final analysis. A total of 3547 patients were included. Redo-SAVR group included 1783 patients, and ViV-TAVI included 1764 subjects. Redo-SAVR showed a higher incidence of all-cause mortality within 30-days [Hazard ratio (HR) 2.12; 95% CI = 1.49−3.03; p < 0.0001)], whereas no difference was observed between 30 days and 1 year (HR = 1.03; 95% CI = 0.78−1.33; p = 0.92). From one year, Redo-SAVR showed a longer benefit (HR = 0.52; 95% CI = 0.40−0.67; p < 0.0001). These results were confirmed for cardiovascular death (HR = 2.04; 95% CI = 1.29−3.22; p = 0.001 within one month from intervention; HR = 0.35; 95% CI = 0.18−0.71; p = 0.003 at 4-years follow-up). Conclusions. Although the long-term outcomes seem similar between Redo-SAVR and ViV-TAVI at a five-year follow-up, ViV-TAVI shows significative lower mortality within 30 days. This advantage disappeared between 30 days and 1 year and reversed in favor of redo-SAVR 1 year after the intervention.

Late outcomes of valve-in-valve transcatheter aortic valve implantation versus re-replacement: Meta-analysis of reconstructed time-to-event data

AIMS

To evaluate all-cause mortality in ViV-TAVI versus redo SAVR in patients with failed bioprostheses.

METHODS

Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of non-randomized studies published by September 30, 2021.

RESULTS

Ten studies met our eligibility criteria and included a total of 3345 patients (1676 patients underwent ViV-TAVI and 1669 patients underwent redo SAVR). Pooling all the studies, ViV-TAVI showed a lower risk of all-cause mortality in the first 44 days [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.49-0.93, P = 0.017], with an HR reversal after 197 days favoring redo SAVR (HR 1.53; 95% CI 1.22-1.93; P < 0.001). Pooling only the matched populations (1143 pairs), ViV-TAVI showed a lower risk of all-cause mortality in the first 55 days [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.45-0.89, P < 0.001], with a reversal HR after 212 days favoring redo SAVR (HR 1.57; 95% CI 1.22-2.03; P < 0.001). The Cox regression model showed a statistically significant association of prosthesis-patient mismatch (PPM) with all-cause mortality during follow-up for ViV-TAVI (HR 1.03 per percentage increase in the study- and treatment arm-level proportion of PPM, 95% 1.02-1.05, P < 0.001).

CONCLUSION

ViV-TAVI is associated with a strong protective effect immediately after the procedure in comparison with redo SAVR, however, this initial advantage reverses over time and redo SAVR seems to be a protective factor for all-cause mortality after 6 months. Considering that these results are the fruit of pooling data from observational studies, they should be interpreted with caution and trials are warranted.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement for Failed Surgical Aortic Bioprostheses: A Systematic Review and Meta-Analysis

Background In the absence of randomized controlled trials, reports from nonrandomized studies comparing valve-in-valve implantation (ViV) to redo surgical aortic valve replacement (rAVR) have shown inconsistent results. Methods and Results PubMed/MEDLINE, Google Scholar, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched through December 2021. Meta-Analysis of Observational Studies in Epidemiology guidelines were followed. The protocol was registered at the International Prospective Register of Systematic Reviews. Random effects models were applied. The primary outcomes of interest were short-term and midterm mortality. Secondary outcomes included stroke, myocardial infarction, acute renal failure, and permanent pacemaker implantation, as well as prosthetic aortic valve regurgitation, mean transvalvular gradient, and severe prosthesis-patient mismatch. Of 8881 patients included in 15 studies, 4458 (50.2%) underwent ViV and 4423 (49.8%) rAVR. Short-term mortality was 2.8% in patients undergoing ViV compared with 5.0% in patients undergoing rAVR (risk ratio [RR] 0.55 [95% CI, 0.34-0.91], P=0.02). Midterm mortality did not differ in patients undergoing ViV compared with patients undergoing rAVR (hazard ratio, 1.27 [95% CI, 0.72-2.25]). The rate of acute kidney failure was lower following ViV, (RR, 0.54 [95% CI, 0.33-0.88], P=0.02), whereas prosthetic aortic valve regurgitation (RR, 4.18 [95% CI, 1.88-9.3], P=0.003) as well as severe patient-prothesis mismatch (RR, 3.12 [95% CI, 2.35-4.1], P<0.001) occurred more frequently. The mean transvalvular gradient was higher following ViV (standard mean difference, 0.44 [95% CI, 0.15-0.72], P=0.008). There were no significant differences between groups with respect to stroke (P=0.26), myocardial infarction (P=0.93), or pacemaker implantation (P=0.21). Conclusions Results of this meta-analysis demonstrate better short-term mortality after ViV compared with rAVR. Midterm mortality was similar between groups. Given the likely selection bias in these individual reports, an adequately powered multicenter randomized clinical trial with sufficiently long follow-up in patients with low-to-intermediate surgical risk is warranted. Registration URL: crd.york.ac.uk/prospero/. Unique identifier: CRD42021228752.

Renal outcomes in valve-in-valve transcatheter versus redo surgical aortic valve replacement: A systematic review and meta-analysis

INTRODUCTION

Postoperative acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) remain common and significant complications of both transcatheter valve-in-valve aortic valve replacement (ViV-TAVR) and redo surgical aortic valve replacement (SAVR). Nevertheless, the understanding of renal outcomes in the population undergoing either redo SAVR or ViV-TAVR remains controversial.

METHODS

A systematic database search with meta-analysis was conducted of comparative original articles of ViV-TAVR versus redo SAVR in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to September 2021. Primary outcomes were AKI and RRT. Secondary outcomes were stroke, major bleeding, pacemaker implantation rate, operative mortality, and 30-day mortality.

RESULTS

Our search yielded 5435 relevant studies. Eighteen studies met the inclusion criteria with a total of 11,198 patients. We found ViV-TAVR to be associated with lower rates of AKI, postoperative RRT, major bleeding, pacemaker implantation, operative mortality, and 30-day mortality. No significant difference was observed in terms of stroke rate. The mean incidence of AKI in ViV-TAVR was 6.95% (±6%) and in redo SAVR was 15.2% (±9.6%). For RRT, our data showed that VIV-TAVR to be 1.48% (±1.46%) and redo SAVR to be 8.54% (±8.06%).

CONCLUSION

Renoprotective strategies should be put into place to prevent and reduce AKI incidence regardless of the treatment modality. Patients undergoing re-intervention for the aortic valve constitute a high-risk and frail population in which ViV-TAVR demonstrated it might be a feasible option for carefully selected patients. Long-term follow-up data and randomized control trials will be needed to evaluate mortality and morbidity outcomes between these 2 treatments.

Two-year outcomes after transcatheter aortic valve-in-valve implantation in degenerated surgical valves

BACKGROUND

Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has emerged in recent years as a safe alternative to redo surgery in high-risk patients. Although early results are encouraging, data beyond short-term outcomes are lacking. Herein, we aimed to assess the 2-year outcomes after ViV-TAVI.

METHODS

Patients undergoing ViV-TAVI for degenerated surgical valves between 2013 and 2019 at the Cleveland Clinic were reviewed. The coprimary endpoints were all-cause mortality and congestive heart failure (CHF) hospitalizations. We used time-to-event analyses to assess the primary outcomes. Further, we measured the changes in transvalvular gradients and the incidence of structural valve deterioration (SVD).

RESULTS

One hundred and eighty-eight patients were studied (mean age = 76 years; 65% males). At 2 years of follow-up, all-cause mortality and CHF hospitalizations occurred in 15 (8%) and 28 (14.9%) patients, respectively. On multivariable analysis, the postprocedural length of stay was a significant predictor for both all-cause mortality (hazard ratio [HR] = 1.1; 95% confidence interval [CI]: 1.01, 1.19) and CHF hospitalization (HR = 1.16; 95% CI: 1.07, 1.27). However, the internal diameter of the surgical valve was not associated with significant differences in both primary endpoints. For hemodynamic outcomes, nine patients (4.8%) developed SVD. The mean and peak transvalvular pressure gradients remained stable over the follow-up period.

CONCLUSION

ViV-TAVI for degenerated surgical valves was associated with favorable 2-year clinical and hemodynamic outcomes. Further studies are needed to better understand the role of ViV-TAVI as a treatment option in the life management of aortic valve disease.

Transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: A systematic review

Background:

Transcatheter aortic valve in valve (Aviv) replacement has been shown to be an effective therapeutic option in patients with failed aortic bioprosthetic valves. This review intended to evaluate contemporary 1-year outcomes of Aviv in recent studies.

Methods:

A systematic review on outcomes of Aviv was performed using the best available evidence from studies obtained using a MEDLINE, Cochrane database, and SCOPUS search. Endpoints of interest were survival, coronary artery obstruction, prosthesis-patient mismatch (PPM), stroke, pacemaker implantation, and structural valve deterioration.

Results:

A total of 3339 patients from 23 studies were included. Mean age was 68–80 years, 20%–50% were female, and Society of Thoracic Surgeons score ranged from 5.7 to 31.1. Thirty-day all-cause mortality ranged from 2% to 8%, and 1-year all-cause mortality ranged from 8% to 33%. Coronary artery obstruction risk after Aviv ranged from 0.6% to 4%. One-year stroke ranged from 2% to 8%. Moderate-severe PPM occurred in 11%–58%, and pacemaker rate at 1 year ranged from 5% to 12%.

Conclusion:

Transcatheter aortic ViV has emerged as an effective therapeutic option to treat patients with failed bioprostheses. The acceptable complication rate and favorable 1-year outcomes make Aviv an appropriate alternative to redo surgical aortic valve replacement.

Meta-Analysis of Valve-in-Valve Transcatheter Aortic Valve Implantation Versus Redo-surgical Aortic Valve Replacement in Failed Bioprosthetic Aortic Valve

This meta-analysis was conducted to compare clinical outcomes of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-surgical aortic valve replacement (Redo-SAVR) in failed bioprosthetic aortic valves. We conducted a comprehensive review of previous publications of all relevant studies through August 2020. Twelve observational studies were included with a total of 8,430 patients, and a median-weighted follow-up period of 1.74 years. A pooled analysis of the data showed no significant difference in all-cause mortality (OR 1.15; 95% CI 0.93 to 1.43; p = 0.21), cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, and the rate of moderate to severe paravalvular leakage between ViV-TAVI and Redo-SAVR groups. The rate of major bleeding (OR 0.36; 95% CI 0.16 to 0.83, p = 0.02), procedural mortality (OR 0.41; 95% CI 0.18 to 0.96, p = 0.04), 30-day mortality (OR 0.58; 95% CI 0.45 to 0.74, p <0.0001), and the rate of stroke (OR 0.65; 95% CI 0.52 to 0.81, p = 0.0001) were significantly lower in the ViV- TAVI arm when compared with Redo-SAVR arm. The mean transvalvular pressure gradient was significantly higher post-implantation in the ViV-TAVI group when compared with the Redo-SAVR arm (Mean difference 3.92; 95% CI 1.97 to 5.88, p < 0.0001). In conclusion, compared with Redo-SAVR, ViV-TAVI is associated with a similar risk of all-cause mortality, cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, and the rate of moderate to severe paravalvular leakage. However, the rate of major bleeding, stroke, procedural mortality and 30-day mortality were significantly lower in the ViV-TAVI group when compared with Redo-SAVR.

Valve-in-valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement: A systematic review and meta-analysis

BACKGROUND/AIM

With the growing contemporary use of bioprosthetic valves, whose limited long-term durability has been well-documented, an increase in the need for reintervention is expected. We perform a meta-analysis to compare the current standard of care, redo surgical aortic valve replacement (Redo SAVR) with the less invasive alternative, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) for treating structural valve deterioration.

METHODS

After a comprehensive literature search, studies comparing ViV TAVR to Redo SAVR were pooled to perform a pairwise meta-analysis using the random-effects model. Primary outcomes were 30-day and follow-up mortality.

RESULTS

A total of nine studies including 9127 patients were included. ViV TAVR patients were significantly older (mean difference [MD], 5.82; p = .0002) and more frequently had hypercholesterolemia (59.7 vs. 60.0%; p = .0006), coronary artery disease (16.1 vs. 16.1%; p = .04), periphery artery disease (15.4 vs. 5.7%; p = .004), chronic obstructive pulmonary disease (29.3 vs. 26.2%; p = .04), renal failure (30.2 vs. 24.0%; p = .009), and >1 previous cardiac surgery (23.6 vs. 15.9%; p = .004). Despite this, ViV TAVR was associated with decreased 30-day mortality (OR, 0.56; p < .0001). Conversely, Redo SAVR had lower 30-day paravalvular leak (OR, 6.82; p = .04), severe patient-prosthesis mismatch (OR, 3.77; p < .0001), and postoperative aortic valve gradients (MD, 5.37; p < .0001). There was no difference in follow-up mortality (HR, 1.02; p = .86).

CONCLUSIONS

Despite having patients with an increased baseline risk, ViV TAVR was associated with lower 30-day mortality, while Redo SAVR had lower paravalvular leak, severe patient-prosthesis mismatch, and postoperative gradients. Although ViV TAVR remains a feasible treatment option in high-risk patients, randomized trials are necessary to elucidate its efficacy over Redo SAVR.

Cardiac conduction abnormalities in patients with degenerated bioprostheses undergoing transcatheter aortic valve-in-valve implantations and their impact on long-term outcomes

BACKGROUND

The relationship between preoperative cardiac conduction abnormalities (CCA) and long-term outcomes after transcatheter aortic valve-in-valve implantation (TAVI-VIV) remains unclear. The aim of the study was to evaluate the effects of preoperative CCA on mortality and morbidity after TAVI-VIV and to estimate the impact of new-onset CCA on postoperative outcomes.

METHODS

Between 2011 and 2020, 201 patients with degenerated aortic bioprostheses were qualified for TAVI-VIV procedures in two German heart centers. Cases with previously implanted permanent rhythm-controlling devices were excluded (n = 53). A total of 148 subjects met the eligibility criteria and were divided into 2 study groups according to the presence of preexisting CCA (CCA (n = 84) and non-CCA (n = 64), respectively). Early and late mortality and morbidity were evaluated. Follow-up functional status was assessed according to New York Heart Association (NYHA) classification.

RESULTS

There were no procedural deaths. TAVI-VIV related new-onset CCAs were observed in 35.8% patients. The 30-day permanent pacemaker implantation rate was 1.6% in non-CCA vs 9.5% in CCA group (p = 0.045). Preexisting right bundle-branch block (OR:5.01; 95%CI, 1.05-23.84) and first-degree atrioventricular block (OR:4.55; 95%CI, 1.10-18.73) were independent predictors of new pacemaker implantation. One-year and five-year probability of survival were comparable in CCA and non-CCA groups: 90.3% vs 91.8% and 68.2% vs 74.3%, respectively. Surviving patients with preexisting and new-onset CCA had a worse functional status according to NYHA classification at follow-up.

CONCLUSION

Preexisting and new-onset postoperative CCAs did not affect early and late mortality after TAVI-VIV procedures, however, they may have a negative impact on late functional status.

Transcatheter valve-in-valve implantation versus surgical redo aortic root replacement in patients with degenerated freestyle aortic bioprosthesis

BACKGROUND

Transcatheter aortic valve-in-valve implantation (ViV TAVI) represents a new treatment option for patients with degenerated aortic bioprosthesis. Comparative data to redo surgical aortic valve replacement (redo SAVR) are limited.

OBJECTIVE

We investigated feasibility and outcome of ViV TAVI versus redo SAVR in patients with symptomatic degenerated Medtronic Freestyle aortic bioprosthesis (FSB).

METHODS

Between January 2002 and February 2020, 25 patients with failed FSB underwent ViV TAVI and 10 patients with failed FSB underwent redo SAVR. Endpoints were defined according to the Valve Academic Research Consortium-2 (VARC-2) criteria.

RESULTS

Age and logistic EuroSCORE II were higher in patients with ViV TAVI (75.4 ± 1.7 vs. 62.9 ± 5.1 years, p = .019; 11.5 ± 1.6 vs. 5.6 ± 5.6%, p = .007). Valve implantation was successful in all cases. Mean transvalvular pressure gradients were significantly lower in patients with redo SAVR than ViV TAVI (7.6 ± 1.0 vs. 10.3 ± 0.8 mmHg, p = .037). Aortic valve regurgitation was absent in 91% and 100% of patients with ViV TAVI and redo SAVR, respectively. Thirty-day mortality rates were 12% in the ViV TAVI cohort versus 0% in the redo SAVR cohort (p = .542). Within the first year after hospital discharge, one patient after ViV TAVI had redo surgical intervention.

CONCLUSIONS

ViV TAVI and redo SAVR lead to excellent functional results in patients with degenerated FSB. Post-procedural early complications must be considered particularly in patients with ViV TAVI because of higher clinical risk profiles.

Balloon-expandable versus self-expanding transcatheter aortic valve replacement for bioprosthetic dysfunction: A systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve-in-valve (VIV) procedure is a safe alternative to conventional reoperation for bioprosthetic dysfunction. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the 2 major types of devices used. Evidence regarding the comparison of the 2 valves remains scarce.

METHODS

A systematic review and meta-analysis was conducted to compare the outcomes of BEV and SEV in transcatheter VIV for aortic bioprostheses dysfunction. A computerized search of Medline, PubMed, Embase, and Cochrane databases was performed. English-language journal articles reporting SEV or BEV outcomes of at least 10 patients were included.

RESULTS

In total, 27 studies were included, with 2,269 and 1,671 patients in the BEV and SEV groups, respectively. Rates of 30-day mortality and stroke did not differ significantly between the 2 groups. However, BEV was associated with significantly lower rates of postprocedural permanent pacemaker implantation (3.8% vs. 12%; P < 0.001). Regarding echocardiographic parameters, SEV was associated with larger postprocedural effective orifice area at 30 days (1.53 cm2 vs. 1.23 cm2; P < 0.001) and 1 year (1.55 cm2 vs. 1.22 cm2; P < 0.001).

CONCLUSIONS

For patients who underwent transcatheter aortic VIV, SEV was associated with larger postprocedural effective orifice area but higher rates of permanent pacemaker implantation. These findings provide valuable information for optimizing device selection for transcatheter aortic VIV.