• Meta-Analysis: ViV TAVR Shows Fewer Complications, Better Early Survival vs. Redo SAVR in Degenerated Valves

    ViV TAVR also shows higher MI, severe patient-prosthesis mismatch

    Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) showed a lower incidence of postoperative complications and better early survival, but also a higher rate of myocardial infarction and severe patient-prosthesis mismatch, as compared to redo surgical aortic valve replacement (SAVR) in degenerated bioprosthetic aortic valves, according to a meta-analysis of 12 observational studies released Monday.

    Michel Pompeu B.O. Sá, MD, MSc, PhD, of the University of Pernambuco-UPE, Recife, Brazil, is the first author of the study, which was published in the Jan. 25 issue of JACC: Cardiovascular Interventions.

    ViV TAVR in patients with bioprosthetic structural valve degeneration (SVD) is an alternative to conventional redo SAVR. Multiple observational studies have shown that it is a feasible option. 

    In this meta-analysis, the authors sought to evaluate the current scenario and compare outcomes between ViV TAVR and redo SAVR. Observational studies comparing ViV TAVR and treat SAVR were identified in a systematic search of published research. A total of 12 publications including a total of 16,207 patients (ViV TAVR, n=8,048; redo SAVR, n=8,159) were included in this meta-analysis.

    Six studies were nonrandomized observational studies with matched populations. All 12 studies in the meta-analysis included a ViV TAVR intervention group and a redo SAVR control group. In most of the studies, patients in the ViV TAVR group were older, with higher frequencies of comorbidities and a higher Society of Thoracic Surgeons risk score.

    In the pooled analysis, ViV TAVR was associated with lower 30-day mortality (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.32-0.87; p=0.017), and significantly lower rates of stroke, major bleeding shorter hospital stay. Thirty-day mortality was also significantly lower in the matched population comparing ViV TAVR to redo SAVR (OR, 0.41; 95% CI, 0.27-0.63; p=0.003). ViV TAVR was associated with significantly higher rates of myocardial infarction and severe patient prosthesis mismatch when compared to redo SAVR.

    This study is noted to have some limitations. A clustered analysis according to the type of the biological valve and mechanism of failure was not performed because of lack of individual patient data. Long-term comparative data were not available due to a shorter follow-up duration of <5 years in the studies.

    In an accompanying editorial, Marc Spaziano, MD, and colleagues, of McGill University Health Center, Montreal, indicated that the retrospective nature of the included observational studies may subject findings to the confounding bias. Also, further studies are needed to evaluate the efficacy of ViV TAVR in patients with a high risk of coronary occlusion due to low coronary height and anticipated patient-prosthesis mismatch.

    The authors of the meta-analysis concluded that ViV TAVR is a valuable option in treating degenerated aortic bioprostheses because of its lower incidence of post-operative complications and better early survival in comparison with redo SAVR. However, VIV TAVR was also associated with higher rates of myocardial infarction and severe patient-prosthesis mismatch.

    The authors urged randomized clinical trials and longer follow-up duration to better compare ViV TAVR and redo SAVR as treatment for failed bioprosthetic aortic valves.

     

    Sources

    Sá MPBO, Van den Eynde J, Simonato M, et al. Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement: An Updated Meta-Analysis. JACC Cardiovasc Interv 2021;14:211–20.

    Spaziano M, Levett JY, Piazza N. Failing Surgical Aortic Valve? It Is Time for a Change. JACC Cardiovasc Interv 2021;14:221–3.

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