Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) and redo surgical aortic valve replacement (SAVR) are associated with comparable mortality rates, according to a new study published in the Journal of Thoracic and Cardiovascular Surgery.[1] A close look at the data, however, revealed some noteworthy differences between the two treatment options.
“While several studies have shown that initial treatment with TAVR may be reasonable in patients of all risk categories, and may be the option that many patients prefer, a detailed discussion of both present and future options is warranted for patients to truly be able to make informed decisions,” wrote first author Sarah Yousef, MD, with the department of cardiothoracic surgery at the University of Pittsburgh, and colleagues. “For example, if a patient undergoes transcatheter aortic valve replacement (TAVR) now, how long is it expected to last them, and what are the future options and their associated risks and benefits? Similarly, a pathway of future expectations and options should be discussed if SAVR is pursued. In order for clinicians to counsel patients through this decision-making, we must have a data-informed understanding of the long-term implications with each of the various treatment plans.”
Yousef et al. tracked data from more than 4,000 TAVRs and more than 2,000 SAVRs performed from 2011 to 2022 at a single facility. Among those patients, 198 underwent ViV TAVR and 147 underwent isolated redo SAVR. A cerebral protection device was used for all ViV TAVRs. Patients were excluded from this analysis if they also underwent another operation—mitral valve repair, for instance—at the same time.
The researchers noted that patients in the ViV TAVR group were significantly older (mean age of 79.5 years old) than patients in the redo SAVR group (mean age of 65 years old). ViV TAVR patients were also associated with significantly higher rates of peripheral vascular disease, chronic lung disease, and New York Heart Association Class III or IV heart failure; in other words, this group faced a much higher baseline risk than the redo SAVR patients.
Overall, operative mortality was 2% in both groups and Kaplan-Meier survival estimates were similar after one year. Redo SAVR patients, meanwhile, were more likely to develop renal failure that required dialysis or require a permanent pacemaker. As one might expect, redo SAVR was also linked to a much longer mean length of stay (8 days vs. 2 days).
ViV TAVR did have much higher rates of postprocedural stroke (2.5% vs. 0.6%) and reintervention for myocardial infarction (1.5% vs. 0%) than redo SAVR. The ViV TAVR group was also associated with significantly higher mean gradients after 30 days (13 vs. 8) and after one year (14 vs. 7.5).
“This study is one of the largest single-center studies comparing outcomes after ViV TAVR versus redo SAVR,” the authors wrote. “Operative mortality was similarly low in the two groups, and patients in the ViV TAVR group had significantly fewer postprocedural complications, despite their substantially higher baseline risk.”
The researchers also emphasized that many patients will not be considered candidates for both ViV TAVR and redo SAVR. Redo SAVR may be the first choice if a TAVR patient needs another intervention later in life, for example, but if surgery is considered too risky for them, they would be treated with ViV TAVR instead.
Still, it remains important to track these data as time goes on. As the group noted, the continued success of TAVR has only grown in recent years; learning as much as possible about managing those patients through the rest of their lives is vital.
Read the full study here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.