Introduction:
There has been a recent trend towards the increased use of biologic valves at the time of surgical aortic valve replacement (SAVR) with an understanding there may be a potential need for future valve intervention. In this study, we compared the clinical outcomes of Redo-SAVR with valve-in-valve transcatheter aortic valve replacement (VIVTAVR) in patients with a prior history of SAVR.
Methods:
From 2012 to 2019, 263 patients underwent isolated aortic valve reintervention after prior SAVR: VIV-TAVR (n=187) or redo-SAVR (n=86). Multivariable analysis was performed to identify risk factors mortality and aortic reintervention. Sub-analyses were performed to compare VIV-TAVR patients to Redo-SAVR patients undergoing biologic valve explant and implant (Biologic) as well as VIV-TAVR and Redo-SAVR patients matched by STS Predicted Risk of Mortality (STS PROM).
Results:
Operative mortality for the Redo-SAVR and VIV-TAVR was 1.2% (1) and 1.6% (3) respectively (p=0.92). Redo-SAVR patients had an increased stroke rate (7.0% vs 1.1%, p=0.02) and longer postoperative length of stay (7 vs 2 days, p<0.0001). VIV-TAVR patients had a higher rate of ≥1+ paravalvular leak (PVL) (21.4% versus 3%, p=0.0002) and a lesser reduction in transvalvular gradient (-21.9 ± 17.6mmHg vs -30.3 ± 20.7mmHg, p=0.0038). The difference in PVL was maintained during the Biologic Sub-analysis (p=0.0034). In the STS PROM Sub-analysis, early mortality was the same for each group (1.2%), and the differences in PVL (p=0.0002) and in transvalvular gradient reduction (p=0.005) were maintained. Preoperative renal failure (p=0.006) and cerebrovascular disease (p=0.04) were risk factors for mortality and prior myocardial infarction (p=0.04) was a risk factor for aortic reoperation for VIV-TAVR. No risk factors were identified for Redo-SAVR.
Conclusions:
Aortic valve reintervention following prior SAVR is associated with outstanding clinical outcomes. Both Redo-SAVR and VIV-TAVR can be performed with lower than expected predicted mortality. Redo-SAVR was associated with increased morbidity compared to VIV-TAVR, but improved valve function and hemodynamics. Differences in long term valve durability and patient survival between these two therapies are yet to be determined.
Incidence, Risk Factors, and Outcomes of Coronary Obstruction Following Valve-in-Valve Transcatheter Aortic Valve Replacement
