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Transcatheter Aortic Valve Implantation in Failed Bioprosthetic Surgical Valves
Study Questions:
What are the clinical outcomes of patients with degenerated bioprosthetic aortic valve replacement (BPAVR) treated with transcatheter aortic valve replacement (TAVR)?
Methods:
This registry evaluated outcomes for 459 patients with degenerated BPAVR (stenosis in 39%, regurgitation in 30%, combined in 30%) treated with valve-in-valve TAVR at 55 sites. Patient outcomes included all-cause mortality, stroke, and New York Heart Association (NYHA) functional class. BPAVRs included both stented (80%) and stentless (20%) valves.
Results:
Mean age was 78 ± 10 years, and 56% were male. Patients were treated with either a self-expandable (n = 213) or balloon-expandable (n = 246) device. Small valves (label size ≤21 mm) were more frequent in patients with stenosis as compared to those with regurgitation or combined degeneration (37% vs. 21% vs. 27%, p = 0.005). Overall 30-day mortality was 8% (35/459), and was more common in those with stenosis as compared to regurgitation or combined disease (11% vs. 4% vs. 7%, p = 0.04). Major stroke was observed in 2% (8/459), and major vascular complications were observed in 9% (42/459). At least moderate aortic regurgitation was observed in 5% (25/459) overall, and was more common in those with baseline regurgitation as compared to those with stenosis or combined disease (9% vs. 3% vs. 5%, p = 0.04). All-cause mortality at 1 year was 17% (62/459), and was more common in those with stenosis as compared to regurgitation or combined disease (23% vs. 9% vs. 16%, p = 0.01). Patients with small valves had lower 1-year survival as compared to those with intermediate or large valves (75% vs. 82% vs. 93%, p = 0.001). NYHA class I or II was observed in 83% at 1 year. Multivariable analysis identified small valve size (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.7; p = 0.02) and baseline stenosis (HR, 3.1; 95% CI, 1.3-7.1; p = 0.008) as independent predictors of mortality at 1 year.
Conclusions:
Valve-in-valve TAVR for degenerated BPAVR results in 83% survival at 1 year. Individuals with smaller valves and those with BPAVR stenosis experience higher rates of mortality.
Perspective:
Degenerated BPAVRs represent a significant clinical problem, as many patients are at high or prohibitive risk for surgical redo AVR. The data from this registry represent a large cross-section of sites implanting both self-expanding and balloon-expandable valves, and represent real-world results. One-year survival was 83% overall, and these findings suggest that valve-in-valve TAVR represents a potential treatment option for some patients. As we develop best-practice approaches and improve our understanding of which patients most benefit from this approach, outcomes may further improve. The observations that mortality is higher in patients with small BPAVRs and those with BPAVR stenosis identify cohorts that may have less benefit, and further research is needed to more precisely determine when valve-in-valve TAVR is likely to be helpful.
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