Valve-in-valve transcatheter aortic valve replacement (TAVR) is a safe and feasible treatment option for patients presenting with structural valve degeneration (SVD) after surgical aortic valve replacement (SAVR), according to new findings published in the American Journal of Cardiology.[1]
“Valve-in-valve TAVR is expected to become increasingly relevant in the lifetime management of aortic stenosis,” wrote first author Danial Ahmad, MD, MPH, with the department of cardiothoracic surgery at the University of Pittsburgh School of Medicine, and colleagues. “Despite its recent approval, preliminary results for valve-in-valve TAVR have been promising in carefully selected patients, however, long-term outcomes remain unclear. Valve-in-valve TAVR is also becoming an attractive alternative to redo SAVR in high-risk patients.”
To gain a better understanding of the procedure’s potential, Ahmad et al. explored data from more than 3,500 patients who underwent traditional native-valve TAVR or valve-in-valve TAVR from 2013 to 2022. While 3,334 patients (94.4%) underwent TAVR, the remaining 198 (5.6%) underwent valve-in-valve TAVR.
Patients undergoing valve-in-valve TAVR had a mean age of 79.5 years old and 42.4% were women. Their mean Society of Thoracic Surgeons (STS) risk score was 6.28. For other TAVR patients, meanwhile, the mean age was 84 years old, 47.5% were women and the mean STS risk score was 4.46.
Severe aortic insufficiency (31% vs. 1.59%), atrial fibrillation (52% vs. 37.5%), prior coronary artery bypass graft procedures (43% vs. 19%) and New York Heart Association class IV heart failure (20.7% vs. 13.5%) were all more common among valve-in-valve TAVR patients. In addition, the mean baseline valve size was smaller among valve-in-valve TAVR patients (25.3 mm) than other TAVR patients (26.9 mm).
Overall, the rates of in-hospital mortality, overall mortality and post-TAVR stroke were comparable between the two patient groups. Many other clinical outcomes were also similar.
On the other hand, valve-in-valve (VIV) TAVR was associated with more major vascular complications (2.5% vs. 0.8%), but fewer arrhythmias requiring a permanent pacemakers (2.5% vs. 8.1%) and a lower mean left ventricular ejection fraction (56.5% vs. 58%) when compared to traditional native-valve TAVR.
Another key difference was visible when viewing echocardiography results. VIV TAVR patients had a higher mean aortic valvular gradient after one year (14 mmHg vs. 10 mmHg), but the mean aortic valve areas were similar between the two groups.
“Our results show that valve-in-valve TAVR patients had comparable in-hospital mortality to native-valve TAVR, which is in conformity with previously reported data,” the authors wrote. “Further, the valve-in-valve population was less likely to receive a permanent pacemaker, which is line with clinical expectations.”
The researchers also explained why they chose to spend so much time focusing on traditional TAVR patients in their analysis.
“The valve-in-valve TAVR populations and native-valve TAVR populations are clearly different with respect to baseline,” they wrote. “This study is not intended to compare both procedures to each other. Rather, it is to assess the safety and feasibility of valve-in-valve TAVR, a newly approved treatment paradigm, to native-valve TAVR, which is an established procedure supported by validated data. Since our valve-in-valve TAVR population was defined as those patients who had had a previous SAVR, it is unknown how the second TAVR intervention would fare if the initial intervention was transcatheter (TAV-in-TAV) or surgical (TAV-in-SAV). A third intervention should also be considered as certain patients do require it and more may do so in the future.”
Overall, the team concluded, these findings show that valve-in-valve TAVR is a “feasible and safe strategy for high-risk patients with SVD/bioprosthetic valve failure.”
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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.