Why the study?
Because life expectancy may exceed bioprosthesis durability in aortic stenosis, the choice of initial valve requires understanding the relative safety and efficacy of potential subsequent TAVR in failed transcatheter versus surgical aortic valves.
Cohort (n=330)
Yes
Absolute Event Rate: 72.7% vs 62.4%
p-value: p=0.045
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“I was troubled to publish these data given the potential confusion it can create, but we must understand that in the Registry, redo-TAVR for probable device failure constituted only 0.22% of the overall 63,876 TAVR procedures. This low rate reflects the relative durability of the valves and also the competing risk of mortality in the elderly and high-risk patients undergoing TAVR so far.”
“For patients in their 50s or 60s, aortic valve disease may require not only two but potentially even three procedures over decades. What is the way to do this? On one end of the spectrum, if you do it young enough and they need three procedures, you could do surgery-surgery-surgery. Nobody's going to accept that. At the other end, you could potentially do TAVR-TAVR-TAVR, which has some problems.”
“I think it's premature. If we know we have a good 10 years for a TAVI valve, then we can go ahead and put these valves in younger patients.”
Comparative study reveals safety and efficacy outcomes in patients undergoing redo transcatheter aortic valve replacement, indicating viable reintervention strategies for failing bioprostheses.
BACKGROUND Surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) are now both used to treat aortic stenosis in patients in whom life expectancy may exceed valve durability. The choice of initial bioprosthesis should therefore consider the relative safety and efficacy of potential subsequent interventions. OBJECTIVES The aim of this study was to compare TAVR in failed transcatheter aortic valves (TAVs) versus surgical aortic valves (SAVs). METHODS Data were collected on 434 TAV-in-TAV and 624 TAV-in-SAV consecutive procedures performed at centers participating in the Redo-TAVR international registry. Propensity score matching was applied, and 330 matched (165:165) patients were analyzed. Principal endpoints were procedural success, procedural safety, and mortality at 30 days and 1 year. RESULTS For TAV-in-TAV versus TAV-in-SAV, procedural success was observed in 120 (72.7%) versus 103 (62.4%) patients (p = 0.045), driven by a numerically lower frequency of residual high valve gradient (p = 0.095), ectopic valve deployment (p = 0.081), coronary obstruction (p = 0.091), and conversion to open heart surgery (p = 0.082). Procedural safety was achieved in 116 (70.3%) versus 119 (72.1%) patients (p = 0.715). Mortality at 30 days was 5 (3%) after TAV-in-TAV and 7 (4.4%) after TAV-in-SAV (p = 0.570). At 1 year, mortality was 12 (11.9%) and 10 (10.2%), respectively (p = 0.633). Aortic valve area was larger (1.55 ± 0.5 cm2 vs. 1.37 ± 0.5 cm2; p = 0.040), and the mean residual gradient was lower (12.6 ± 5.2 mm Hg vs. 14.9 ± 5.2 mm Hg; p = 0.011) after TAV-in-TAV. The rate of moderate or greater residual aortic regurgitation was similar, but mild aortic regurgitation was more frequent after TAV-in-TAV (p = 0.003). CONCLUSIONS In propensity score-matched cohorts of TAV-in-TAV versus TAV-in-SAV patients, TAV-in-TAV was associated with higher procedural success and similar procedural safety or mortality.
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Landes et al. (2021) conducted a cohort in Aortic stenosis with failed bioprostheses (n=330). TAV-in-TAV vs. TAV-in-SAV was evaluated on Procedural success (p=0.045).
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