Outcomes for TAVR Valve-in-Valve Implantation

Study Questions:

What are the intermediate-term outcomes in patients treated with transcatheter valve-in-valve (VinV) implantation?

Methods:

This study examined outcomes in 73 patients treated with transcatheter VinV implantation for aortic (n = 42) or mitral (n = 31) bioprosthetic valve dysfunction using an Edwards balloon-expandable transcatheter valve. All patients were considered at prohibitive risk for conventional valve replacement.

Results:

Median follow-up was 2.5 years. The procedure was successful in 99% (72/73) of cases. Adverse events at 30 days of follow-up included all-cause mortality in 1%, disabling stroke in 1%, life-threatening bleeding in 4%, kidney injury requiring hemodialysis in 3%, and intervention for coronary obstruction in 1%. All patients had ≤ mild paravalvular regurgitation. Survival at 1, 2, 3, 4, and 5 years was 89%, 80%, 70%, 62%, and 41%, respectively. Median survival was 4.5 years for aortic and 4.4 years for mitral VinV implantation. On multivariable analysis in patients treated with aortic VinV, a surgical valve size <23 mm was associated with increased mortality (hazard ratio, 6.2; 95% confidence interval, 1.01-22.8; p = 0.01).

Conclusions:

Transcatheter VinV implantation for dysfunctional aortic or mitral bioprosthetic valves has high procedural success and has acceptable outcomes in a cohort at prohibitive risk of redo surgical valve replacement.

Perspective:

Prior studies have demonstrated that transcatheter VinV implantation is feasible in patients with dysfunctional aortic and mitral bioprosthetic valve replacements, and is associated with reasonable short- and intermediate-term outcomes. This study examines a larger cohort with intermediate-term follow-up, and procedural success and outcomes appear acceptable in this cohort. These results suggest that this may be a reasonable option for patients at prohibitive risk of redo surgical valve replacement. While we have limited data on longer-term follow-up, estimated 5-year survival in this extreme-risk cohort was only 41%. This suggests that we need better strategies to identify which patients are more or less likely to benefit from this.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Aortic Valve Insufficiency, Bioprosthesis, Cardiac Surgical Procedures, Heart Valve Diseases, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation, Mitral Valve Insufficiency, Prostheses and Implants, Renal Dialysis, Stroke, Transcatheter Aortic Valve Replacement


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