Valve-in-valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement in patients with degenerated aortic bioprostheses: Three-year death rates and haemodynamic performance

BACKGROUND: Management of degenerated aortic bioprostheses through valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) or redo surgical aortic valve replacement (Re-SAVR) shows similar short-term safety and efficacy. However, long-term survival and haemodynamic performance data are limited. AIM: To compare clinical characteristics, haemodynamics and outcomes at 3 years between ViV-TAVR and Re-SAVR techniques. METHODS: This retrospective two-centre study included 266 patients treated for isolated aortic bioprosthesis degeneration (130 Re-SAVR, 136ViV-TAVR) from 2009 to 2018, with up to 3 years of follow-up. RESULTS: The ViV-TAVR group was older (83 vs. 77 years; P=0.005) with higher surgical risk (Logistic EuroSCORE 22% vs. 13%; P=0.005). At 3 years, univariate analysis showed no significant difference in all-cause deaths (22.1% vs. 17.7%; P=0.37). ViV-TAVR was associated with fewer first-month complications, including major bleeding (11.0% vs. 52.3%; P=0.007) and acute renal failure grade 2/3 (5.1% vs. 14.6%; P=0.053). Inverse probability of treatment weighting analysis revealed no difference in all-cause deaths at 1 year (hazard ratio HR 0.78, 95% confidence interval CI 0.36-1.67; P=0.52) or between 1 and 3 years (HR 1.56, 95% CI 0.82-2.99; P=0.17). Composite events were similar at 1 year (HR 0.80, 95% CI 0.44-1.44; P=0.45) and between 1 and 3 years (HR 1.41, 95% CI 0.83-2.38; P=0.21). Mean gradients at 3 years were similar (16.1±11.4 vs. 13.2±5.3mmHg; P=0.17). In patients with small bioprostheses (true internal diameter≤20mm n=151), death rates at 3 years were similar (21.1% vs. 20.0%; P=0.86), as was haemodynamic performance (mean gradient 19.2±14.0mmHg for ViV-TAVR vs. 13.7±4.12mmHg for Re-SAVR P=0.38). Compared to balloon-expandable, self-expandable valves showed better 1-year mean gradients (16.4±10.5 vs. 13.7±4.12mmHg; P=0.012). CONCLUSIONS: ViV-TAVR and Re-SAVR had similar mortality and haemodynamic outcomes at 3 years, including in patients with small bioprostheses where self-expandable valves yielded the best results.