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TAVR a viable option in patients with failed bioprosthetic surgical valves
Patients treated with transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves had a 1-year survival rate of over 80%, concluded results of an international registry published in JAMA.
For the study, Valve-in-Valve International Registry Investigators enrolled 459 patients with failed bioprosthetic surgical valves who underwent valve-in-valve implantation at 55 centers from 2007 to May 2013. Patients had a mean age of 77.6 years and a median Society of Thoracic Surgeons mortality prediction score of 9.8%, and 56% were men.
Surgical valve size was defined as small (≤21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%) and large (≥25 mm; 31%). Both balloon- and self-expanding transcatheter valves were implanted.
The main outcome measures were survival, stroke and NYHA functional class.
Researchers observed the following modes of bioprosthesis failure: stenosis (39.4%); regurgitation (30.3%); and combined stenosis/regurgitation (30.3%). Small valves were more common in the stenosis group (37%) than the regurgitation (20.9%) or combined (26.6%; P=.005) groups.
One month following valve-in-valve implantation, the mortality rate was 7.6%, and 1.7% of patients experienced major stroke. Also at this time point, 92.6% of surviving patients had good functional status, defined as NYHA functional class I or II.
At 1 year, Kaplan-Meier survival was 83.2% (95% CI, 80.8%-84.7%). Patients in the stenosis group had the lowest rate of survival (76.6% vs. regurgitation, 91.2%; combined, 83.9%; P=.01), as did patients with small valves (74.8% vs. intermediate, 81.8%; large, 93.3%; P=.001).
Both small surgical bioprosthesis (HR=2.04; 95% CI, 1.14-3.67; P=.02) and baseline stenosis (vs. regurgitation; HR=3.07; 95% CI, 1.33-7.08; P=.008) were predictors of 1-year mortality.
“The current analysis highlights the need for meticulous evaluation of bioprosthesis mechanism of failure before attempting a valve-in-valve procedure,” the researchers wrote. “Patients who are diagnosed as having failed surgical valves secondary to stenosis should be further separated into those with degenerated valves and those who have elevated gradients and small effective orifice area as a result of severe [prosthetic patient mismatch] with their surgical valve.”
Disclosure: The researchers report financial disclosures with Abbott, Biotronik, Boston Scientific, Claret Medical, Cordis, Direct Flow Medical, Edwards Lifesciences, JenaValve, Medtronic, Merril Lifesciences, St. Jude Medical, Symetis and Thubrikar.