Long-term survival after valve-in-valve TAVR similar with self-expanding, balloon-expandable valves
Self-expanding (SE) and balloon-expandable (BE) transcatheter heart valves are associated with comparable long-term survival rates after valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), according to new data published in The American Journal of Cardiology.[1]
“By virtue of design, these valves have differences in stent frames, leaflet features, and modes of expansion, which could translate to varying hemodynamic profiles with consequent impact on outcomes,” wrote corresponding author Ibrahim Sultan, MD, chief of cardiac surgery at the University of Pittsburgh School of Medicine, and colleagues. “Although these valve systems have been extensively studied in native-valve TAVRs, little is known about their performance when used in the ViV context of a failed surgical bioprosthetic heart valve (BHV). This context offers added complexities when compared with native-valve TAVRs such as the presence of existing valve leaflets, increased risk of thrombosis, and increased risk of prosthesis-patient mismatch (PPM), especially in the setting of a small surgical BHV.”
Sultan et al. tracked data from 315 patients who underwent ViV TAVR from 2013 to 2023. The median age was 77 years old, 42.5% of patients were women and 87.9% were white. All patients were treated with a cerebral protection device.
While 73% of patients received an SE TAVR valve, the other 27% received a BE valve. Patients were divided into 81 matched pairs with comparable Society of Thoracic Surgeons risk scores, median valve implant sizes and other baseline characteristics.
Technical success rates and in-hospital mortality were not significantly different between the two groups, though the median length of stay was slightly longer for BE patients (two days) than SE patients (one day).
After 30 days, meanwhile, the all-cause mortality and hospital readmission rates were comparable. No strokes occurred in either group during that time.
On the other hand, some differences did stand out after those first 30 days. The SE group was associated with a greater indexed defective orifice area (0.7 cm2/m2 vs. 0.6 cm2/m2), but lower mean aortic valve gradients (14 mm Hg vs. 17.5 mm Hg). In addition, the rate of severe prosthesis-patient mismatch (PPM) was higher among BE patients (16%) than SE patients (6.2%).
Jumping ahead in time, all-cause mortality, hospital readmission and stroke were all comparable one year following ViV-TAVR. Echo results confirmed SE patients were still associated with lower mean aortic valve gradients (14 mm Hg vs. 17 mm Hg).
The group then explored long-term outcomes, noting that survival after five years was comparable for the two groups in both the unmatched and matched patient populations. Five-year stroke rates were also not significantly different.
“Our findings suggest that ViV-TAVR (TAV-in-surgical aortic valve) is a safe and reasonable mode of treatment for failed surgical BHVs with no unequivocal superiority of one valve system to the other,” the authors wrote. “In addition, ViV-TAVR reportedly has comparable outcomes to those of native-valve TAVR. As such, it should be considered a safe option for eligible patients. Given the increasing use of surgical bioprosthetic valves in younger patients, lifetime management of aortic stenosis should be considered when determining the initial treatment because the first choice of implanted valve affects the choice and outcomes of subsequent interventions.”
Another key takeaway from the group’s research was the relationship between severe PPM and clinical outcomes.
“PPM after TAVR has been associated with worse survival especially if severe. However, in the present study, we found no difference in survival between the groups despite higher rates of severe PPM at 30 days in the BE group,” the authors wrote. “This finding is similar to the studies reporting no association between PPM and prognosis after TAVR. Despite PPM not portending worse survival in our ViV-TAVR cohort, evaluation of long-term survival outcomes in a larger cohort is needed to definitively determine the association of PPM with survival.”
Sultan and colleagues did note that PPM was estimated using echo-derived EOA data, which “may not be completely representative” of the actual PPM rates. They viewed this as one of their study’s limitations, along with its “retrospective and observational nature.”
Click here to read the full analysis in The American Journal of Cardiology.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.