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ViV TAVR vs. Redo Surgery for Failed Biological Prostheses
Study Questions:
What are early and late outcomes between redo surgical aortic valve replacement (AVR) and valve-in-valve (ViV) transcatheter AVR (TAVR) for failed biological prostheses?
Methods:
The investigators linked clinical and administrative databases for Ontario, Canada’s most populous province to obtain patients undergoing ViV and redo surgical AVR (RS) for failed previous biological prostheses. Propensity score matching was performed to account for differences in baseline characteristics. Early outcomes were compared using the McNemar test. Late mortality was compared between the matched groups using a Cox proportional hazards model.
Results:
A total of 558 patients undergoing intervention for failed biological prostheses between March 31, 2008, and September 30, 2017, at 11 Ontario institutions (ViV, n = 214; RS, n = 344) were included. Patients who underwent ViV were older and had more comorbidities. Propensity matching on 27 variables yielded similar groups for comparison (n = 131 pairs). Mean time from initial AVR to RS or ViV was 8.6 ± 4.4 years and 11.3 ± 4.5 years, respectively. Thirty-day mortality was significantly lower with ViV compared with RS (absolute risk difference, −7.5%; 95% confidence interval, −12.6% to −2.3%). The rates of permanent pacemaker implantation and blood transfusions were also lower with ViV, as was length of stay. Survival at 5 years was higher with ViV (76.8% vs. 66.8%; hazard ratio, 0.55; 95% confidence interval, 0.30 to 0.99; p = 0.04).
Conclusions:
The authors concluded that ViV TAVR was associated with lower early mortality, morbidity, and length of hospital stay and with increased survival compared with redo surgical AVR, and may be the preferred approach for the treatment of failed biological prostheses.
Perspective:
This propensity-matched study comparing ViV TAVR with redo surgical AVR reports that perioperative mortality was significantly lower with ViV TAVR and the rate of postoperative complications, including pacemaker implantation, blood transfusions, and length of hospital stay was also significantly lower with ViV TAVR. Furthermore, overall survival remained improved at 5 years in the ViV TAVR cohort. These data suggest that in patients at intermediate and high risk, ViV TAVR may be the preferred treatment of choice in patients with suitable anatomy. Additional follow-up studies with echocardiographic measurements are indicated to ensure that late aortic valve gradients remain favorable in both groups.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Blood Transfusion, Cardiac Surgical Procedures, Echocardiography, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Length of Stay, Pacemaker, Artificial, Prosthesis Failure, Secondary Prevention, Transcatheter Aortic Valve Replacement
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