Valve in valve transcatheter versus redo surgical replacement of a failing surgical bioprosthetic aortic valve: An updated systematic review and meta-analysis

BACKGROUND: With the aging population, degeneration of surgical aortic valves is an important clinical scenario. Currently, in most European countries, both redo surgery [redo-surgical aortic valve replacement (SAVR)] and valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) are established alternatives for treating such patients. This meta-analysis aims to compare redo-SAVR and ViV-TAVI for treating a failing bioprosthetic aortic valve. METHODS: A systematic search was performed from inception to June 2023. After selecting all appropriate trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a random effect meta-analysis was performed. Clinical and echocardiographic outcomes were compared among the groups. RESULTS: Twenty-six studies with a total of population of 17,581 patients were included [ViV-TAVI (n = 9163) or redo-SAVR (n = 8418]. ViV-TAVI was associated with lower 30-day mortality (RR: 0.55; 95%CI: 0,47 to 0,66) and 1-year mortality (RR: 0.85; 95%CI: 0.75 to 0.96), major bleeding events (RR: 0.58; 95%CI: 0.42-0.79), and a trend towards lower new pacemaker implantations (RR: 0.70; 95%CI: 0.49-1.01) at 30 days. On the other hand, ViV-TAVI resulted in a higher mean transprosthetic gradient and higher rates of severe patient-prosthesis mismatch (RR: 1.64; 95%CI: 1.01 to 2.65) and paravalvular leak (RR: 2.44; 95%CI: 1.73-3.45) as compared to redo-SAVR. No significant difference was observed in 30-day myocardial infarction (RR: 0.90; 95%CI: 0.56 to 1.46) or stroke (RR: 0.77; 95%CI:0.55 to 1.06). CONCLUSION: ViV-TAVI has a satisfying safety profile with better short-term survival outcomes as compared to redo-SAVR. However, adequate pre-procedural planning of VIV-TAVI cases is needed, in order to minimize the risk of a suboptimal hemodynamic outcomes following ViV-TAVI.