Valve‐in‐Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement for Failed Surgical Aortic Bioprostheses: A Systematic Review and Meta‐Analysis

Abstract

Background In the absence of randomized controlled trials, reports from nonrandomized studies comparing valve‐in‐valve implantation (ViV) to redo surgical aortic valve replacement (rAVR) have shown inconsistent results. Methods and Results PubMed/MEDLINE, Google Scholar, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched through December 2021. Meta‐Analysis of Observational Studies in Epidemiology guidelines were followed. The protocol was registered at the International Prospective Register of Systematic Reviews. Random effects models were applied. The primary outcomes of interest were short‐term and midterm mortality. Secondary outcomes included stroke, myocardial infarction, acute renal failure, and permanent pacemaker implantation, as well as prosthetic aortic valve regurgitation, mean transvalvular gradient, and severe prosthesis‐patient mismatch. Of 8881 patients included in 15 studies, 4458 (50.2%) underwent ViV and 4423 (49.8%) rAVR. Short‐term mortality was 2.8% in patients undergoing ViV compared with 5.0% in patients undergoing rAVR (risk ratio [RR] 0.55 [95% CI, 0.34–0.91], P =0.02). Midterm mortality did not differ in patients undergoing ViV compared with patients undergoing rAVR (hazard ratio, 1.27 [95% CI, 0.72–2.25]). The rate of acute kidney failure was lower following ViV, (RR, 0.54 [95% CI, 0.33–0.88], P =0.02), whereas prosthetic aortic valve regurgitation (RR, 4.18 [95% CI, 1.88–9.3], P =0.003) as well as severe patient–prothesis mismatch (RR, 3.12 [95% CI, 2.35–4.1], P <0.001) occurred more frequently. The mean transvalvular gradient was higher following ViV (standard mean difference, 0.44 [95% CI, 0.15–0.72], P =0.008). There were no significant differences between groups with respect to stroke ( P =0.26), myocardial infarction ( P =0.93), or pacemaker implantation ( P =0.21). Conclusions Results of this meta‐analysis demonstrate better short‐term mortality after ViV compared with rAVR. Midterm mortality was similar between groups. Given the likely selection bias in these individual reports, an adequately powered multicenter randomized clinical trial with sufficiently long follow‐up in patients with low‐to‐intermediate surgical risk is warranted. Registration URL: crd.york.ac.uk/prospero/ . Unique identifier: CRD42021228752.

Transcatheter Aortic Valve Replacement for Failed Surgical or Transcatheter Bioprosthetic Valves: A Comprehensive Review

“…Although there are no RCTs examining the long-term outcomes of ViV TAVR versus redo-SAVR, several meta-analyses of observational studies have been conducted to compare the short- and long-term outcomes of these procedures. Many of these studies demonstrated a reduction in 30-day mortality in patients who undergo ViV TAVR compared to redo-SAVR, but data regarding long-term mortality outcomes remain limited [ 11 , 37 , 38 , 39 , 40 , 41 ]. In one meta-analysis, 12 studies were included to compare the results of ViV TAVR to redo-SAVR procedures in patients with failed THVs or surgical bioprosthetic valves [ 37 ].…”

“…The study showed no significant difference in the incidence of stroke, acute renal dysfunction, or need for permanent pacemaker placement between both groups [ 38 ]. Another meta-analysis of 15 observational studies found reduced 30-day mortality and acute kidney injury in ViV TAVR patients compared to SAVR patients (2.8% vs. 5.0%, p = 0.02) [ 40 ]. This study found that midterm mortality (1–2 years post-procedure) was similar between the two groups, but the incidence of severe PPM, prosthetic aortic regurgitation, and mean transvalvular gradient was higher in the ViV TAVR group [ 40 ].…”

“…Another meta-analysis of 15 observational studies found reduced 30-day mortality and acute kidney injury in ViV TAVR patients compared to SAVR patients (2.8% vs. 5.0%, p = 0.02) [ 40 ]. This study found that midterm mortality (1–2 years post-procedure) was similar between the two groups, but the incidence of severe PPM, prosthetic aortic regurgitation, and mean transvalvular gradient was higher in the ViV TAVR group [ 40 ]. The incidence of stroke and myocardial infarction and the need for pacemaker placement were similar between the two groups [ 40 ].…”

“…This study found that midterm mortality (1–2 years post-procedure) was similar between the two groups, but the incidence of severe PPM, prosthetic aortic regurgitation, and mean transvalvular gradient was higher in the ViV TAVR group [ 40 ]. The incidence of stroke and myocardial infarction and the need for pacemaker placement were similar between the two groups [ 40 ]. In another meta-analysis of 9 studies, similar findings regarding mortality, severe PPM, and mean transvalvular gradient were observed [ 41 ].…”

The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures

“…It is our opinion that the highest-risk procedure should be performed first while the patients are still young to minimize the need for surgical interventions in older and higher-risk patients in the future [38]. Careful evaluation and planning on the order and sequence of treatment options is essential (Figure 2) [39][40][41][42]. Recent data on reoperations and the valve explanation following TAVR highlight the significant surgical risks involved [43,44].…”