Vol. 48 | No. 2 | July-December 2020 Back

Open Access

Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation Versus Conventional Redo Surgical Aortic Valve Replacement in Patients With Aortic Bioprosthetic Valves: A Meta-analysis

Keith Andrew L. Chan, Francisco L. Chio Jr, Jeremy Anne A. Alcazar, Carlo Andrew A. Buaya, Elaine L. Gallardo
Dec 2020 DOI 10.69944/pjc.164f82d17b

Abstract

BACKGROUND: Studies have demonstrated earlier valve degeneration in patients with bioprosthetic aortic valves (AVs), necessitating redo surgical aortic valve replacement (SAVR). Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is a novel, off-label technique that offers a feasible alternative to SAVR. 

OBJECTIVES: The aim of this study was to determine outcomes of patients with bioprosthetic AVs undergoing ViV-TAVI versus redo SAVR, namely, primary clinical outcomes (procedural and 30-day all-cause mortality), secondary clinical outcomes (30-day myocardial infarction, stroke, acute kidney injury, permanent pacemaker insertion), and echocardiographic parameters (mean postoperative AV gradient, postoperative AV gradients >20 mm Hg, and paravalvular leaks).  

STUDY SELECTION: Criteria included studies having (a) human subjects, (b) recently conducted studies (publication date within 5 years from analysis), (c) patients with prior SAVR   with a bioprosthetic valve, (d) both a ViV-TAVI compared against a redo SAVR arm, (e) follow-up period of 12 or more months, and (f) reported the specified outcomes.  

RESULTS: The analysis included five studies (total: 533 [ViV-TAVI: 249, redo SAVR: 284]). Preoperative risk scores were higher in the ViV-TAVI arm (EuroSCORE: 13 ± 10.4 to 27.4 ± 18.7; Society of Thoracic Surgeons [STS]: 7.4 ± 4.9 to 7.5 ± 3) compared with the redo SAVR arm (EuroSCORE: 8.9 ± 6.5 to 16.8 ± 9.3; STS: 4.4 ± 4.4 to 7.7 ± 3.4). There was no statistically significant difference for procedural and 30-day all-cause mortality. There were also no significant differences in any of the secondary clinical outcomes. Mean postoperative AV gradients had no significant differences between arms, but cases with postoperative AV gradients >20 mm Hg (odds ratio [OR], 5.26; 95% confidence interval [CI], 3.03–9.14; P < 0.00001) and paravalvular leaks (OR, 4.27; 95% CI, 2.01–9.07; P = 0.0002) were significantly higher in the ViV-TAVI group. 

CONCLUSION: Valve-in-valve transcatheter AV implantation is a novel technique being increasingly performed, with procedural and 30-day mortality rates comparable to redo SAVR, even in patients with high preoperative risk. However, its strongest limitation is postoperative valve hemodynamics, with redo SAVR still having a superior postoperative hemodynamic profile. 

KEYWORDS: valve-in-valve transcatheter aortic valve implantation, ViV-TAVI, bioprosthetic aortic valves 

 

References
  1. Eveborn GW, Schirmer H, Heggelund G, et al. The evolving epidemiology of valvular aortic stenosis. The Tromsø study. Heart 2013;99:396–400.
  2. Osnabrugge RLJ, Mylotte D, Head SJ, et al. Aortic stenosis in the elderly. J Am Coll Cardiol 2013;62(11):1002–1012. doi:10.1016/j.jacc.2013.05.015.
  3. Brown JM, O’Brien SM, Wu C, Sikora JA, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg 2009;137:82–90.
  4. Rodriguez-Gabella T, Voisine P, Puri R, Pibarot P, Rodés Cabau J. Aortic bioprosthetic valve durability. J Am Coll Cardiol 2017;70(8):1013–1028.
  5. Gillam L, Koulogiannis K, Marcoff L. Bioprosthetic aortic valve deterioration. Circulation 2018;138(10):986–988. 6. Leontyev S, Borger M, Davierwala P, et al. Redo aortic valve surgery: early and late outcomes. Ann Thorac Surg 2011;91(4):1120–1126.
  6. Webb J, Wood D, Ye J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation 2010;121(16):1848–1857.
  7. Webb J, Dvir D. Transcatheter aortic valve replacement for bioprosthetic aortic valve failure. Circulation 2013;127(25):2542–2550.
  8. Wenaweser P, Buellesfeld L, Gerckens U, Grube E. Percutaneous aortic valve replacement for severe aortic regurgitation in degenerated bio-prosthesis: the first valve in valve procedure using the CoreValve revalving system. Catheter Cardiovasc Interv 2007;70: 760–764.
  9. Carabello B. Valve-in-valve TAVR. J Am Coll Cardiol 2017;69(18):2263–2265.
  10. Webb J, Mack M, White J, et al. Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses. J Am Coll Cardiol 2017;69(18):2253–2262.
  11. Clinicaltrials.gov [website].The National Library of Medicine. The Nordic Aortic Valve Intervention Trial” (ClinicalTrials. gov identifier: NCT01057173). https://clinicaltrials.gov/ct2/ show/NCT01057173. Accessed January 2, 2019.
  12. Neupane S, Singh H, Lämmer J. Meta-analysis of transcatheter valve-in-valve implantation versus redo aortic valve surgery for bioprosthetic aortic valve dysfunction. Am J Cardiol 2018;121(12):1593–1600.
  13. Gozdek M, Raffa G, Suwalski P, et al. Comparative performance of transcatheter aortic valve-in-valve implantation versus conventional surgical redo aortic valve replacement in patients with degenerated aortic valve bioprostheses: systematic review and meta-analysis. Eur J Cardiothorac Surg 2017;53(3):495–504.
  14. Ejiofor JI, Yammine M, Harloff MT, et al. Reoperative surgical aortic valve replacement versus transcatheter valve-in-valve replacement for degenerated bioprosthetic aortic valves. Ann Thorac Surg 2016;102(5):1452–1458. doi:10.1016/jathoracsur.2016.05.086.
  15. Erlebach M, Wottke M, Deutsch MA, et al. Redo aortic valve surgery versus transcatheter valve-in-valve implantation for failing surgical bioprosthetic valves: consecutive patients in a single-center setting. J Thorac Dis 2015;7(9):1494–1500. doi: 10.3978/j.issn.2072-1439.2015.09.24.
  16. Grubitzsch H, Zobel S, Christ T, et al. Redo procedures for degenerated stentless aortic xenografts and the role of valve-in-valve transcatheter techniques. Eur J Cardiothorac Surg 2017;51:653–659.
  17. Silaschi M, Wendler O, Seiffert M, et al. Transcatheter valve-in-valve implantation versus redo surgical aortic valve replacement in patients with failed aortic bioprostheses. Interact CardioVasc Thorac Surg 2017;24:63–70.
  18. Spaziano M, Mylotte D, Thériault-Lauzier P, et al. Transcatheter aortic valve implantation versus redo surgery for failing surgical aortic bioprostheses: a multicentre propensity score analysis. EuroIntervention 2017;13(10):1149–1156.
  19. Saxon J, Allen K, Cohen D, Chhatriwalla A. Bioprosthetic valve fracture during valve-in-valve TAVR: bench to bedside. Interv Cardiol Rev 2017;13(01):20.
  20. Chhatriwalla A, Allen K, Saxon J, et al. Bioprosthetic valve fracture improves the hemodynamic results of valve-in valve transcatheter aortic valve replacement. Circulation Cardiovasc Interv 2017;10(7).
  21. Zenses A, Dahou A, Salaun E, et al Haemodynamic outcomes following aortic valve-in-valve procedure. Open Heart 2018;5:e000854. doi:10.1136/openhrt-2018-000854
License

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, which permits use, share — copy and redistribute the material in any medium or format, adapt — remix, transform, and build upon the material, as long as you give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. You may not use the material for commercial purposes. If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original. You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/.