Impact of reintervention after index aortic valve replacement on the risk of subsequent mortality

Objectives: The use of bioprosthetic aortic valve replacement (AVR) is inherently associated with a risk of structural valve degeneration (SVD) and the need for aortic valve (AV) reintervention.We sought to evaluate whether AV reintervention, in the form of repeat surgical AVR (SAVR) or valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), negatively affects patients' subsequent long-term survival after index SAVR. Methods:We identified patients who had undergone bioprosthetic SAVR from 2002 to 2017 at our institution.Median longitudinal follow-up after index SAVR was 7.3 years (10.9 years for those with and 7.2 years for those without AV reintervention), and median follow-up after AV reintervention was 1.9 years.Cox regression analyses using AV reintervention (re-SAVR and ViV-TAVR) as a time-varying covariate were used to determine the impact of reintervention on subsequent survival.Results: Of 4167 patients who underwent index SAVR, 139 (3.3%) required AV reintervention for SVD, with re-SAVR being performed in 65 and ViV-TAVR in 74.Median age at the index SAVR was 73 years (interquartile range, 64-79 years), and 2541 (61%) were male.Overall, there were total of 1171 mortalities observed, of which 13 occurred after re-SAVR and 9 after ViV-TAVR.AV reintervention was associated with a greater risk of subsequent mortality compared with those patients who did not require AV reintervention (hazard ratio, 2.53; 95% confidence interval, 1.64-3.88,P < .001).This increased risk of subsequent mortality was more pronounced for those who received their index AVR when <65 years of age (hazard ratio, 5.60; 95% confidence interval, 2.57-12.22,P < .001)versus those 65 years (2.06, 1.21-3.52,P .008).Direct comparison of survival between those who underwent re-SAVR versus ViV-TAVR showed 5-year survival to be comparable (re-SAVR: 74% vs ViV-TAVR: 80%, P .67).Conclusions: Among patients receiving bioprosthetic AVR, an AV reintervention for SVD is associated with an increased risk of subsequent mortality, regardless of re-SAVR or ViV-TAVR, and this risk is greater among younger patients.These findings should be balanced with individual preferences at index AVR in the context of patients' lifetime management of aortic stenosis.(JTCVS Open 2023;16:93-102) Risk of mortality is more than 2x higher in patients who underwent AV reintervention HR 2.53 [1.64 -3.88] Increased mortality risk for those who received index AVR < 65 versus those t t 65 HR 5.60 [2.57-12.22] vs. HR 2.06 [1.21 -3.52] Survival between re-SAVR versus ViV-TAVR patients showed comparable 5-year survival 74% vs. 80% All patients with bioprosthetic aortic valve replacements Repeat Procedure on AV for SVD No repeat procedure N = 4028 N = 65 N = 74 Re-do SAVR ViV-TAVR Repeat Procedure on AVAfter AVR, AV reintervention is associated with an increased risk of mortality.