A large registry study shows lower survival for valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) for small failed bioprosthetic valves compared to larger prostheses.
Danny Dvir, MD of Shaare Zedek Medical Center, Hebrew University, Jerusalem, and University of Washington, presented the study Thursday at the PCR e-Course.
Currently, long-term data after ViV TAVR procedures are limited. The VIVID registry is a retrospective, multicenter database that includes transcatheter ViV TAVRs performed before December 2014. A total of 1,006 ViV TAVR procedures were included. Of these, 523 procedures involved Medtronic self-expanding valves, and 435 were performed with balloon-expandable valves.
The patients’ overall mean age was 77.7 years, and 59% were men. Small bioprosthetic valves were defined as those with true internal diameter (ID) <20 mm. About 6% had pre-existing severe patient-prosthesis mismatch (PPM). The patients’ mean Society of Thoracic Surgeons score was 7.3%, and 70% underwent ViV TAVR via transfemoral access.
Significant differences in multiple baseline characteristics were noted between patients who received Medtronic self-expanding valves and those who received Edwards Lifesciences balloon-expandable valves. Overall, patients who underwent ViV TAVR with a balloon-expandable valve were older, with a higher incidence of peripheral arterial disease and with a higher non-transfemoral approach.
Long-term survival at 8 years was 38%. Survival was lower at 8 years in patients with small failed bioprostheses (ID ≤20 mm) than in patients with large failed bioprostheses (ID >20 mm) (33.2% vs. 40.5%, p=0.01). On a multivariable analysis, true ID per 1-mm decrease, age per 10-year increase, baseline left ventricular ejection fraction per 10% decrease, chronic kidney disease, non-transfemoral access, and diabetes were significant predictors of all-cause mortality.
About 40 reinterventions were performed after ViV TAVR. On a multivariable analysis, balloon-expandable valves, malposition, and pre-existing severe PPM were positive predictors, and age per 10-year increase was a negative predictor for all-cause reintervention. There were higher rates of reintervention with balloon-expandable valves than with self-expanding valves (balloon-expandable valves 6% vs. self-expanding valves 2%; hazard ratio, 3.34; 95% confidence interval, 1.26-8.85; p=0.02).
Dvir concluded that the size of the original failed valve may influence long-term mortality, and type of valve may influence need for reintervention after ViV TAVR. He stated that decisions with regard to the size and type of valve made by the operator during original tissue valve implantation and during ViV procedures influence clinical outcomes.
PCR e-Course is the virtual meeting being held in place of the annual in-person EuroPCR congress, which was canceled because of the COVID-19 pandemic.