Incidence and Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation in Failed Bioprosthetic Valves

Abstract

Highlights: What is known? Transcatheter aortic valve replacement (TAVR) has become the standard of care beside sur-gical valve replacement (SAVR) in the majority of patients with aortic stenosis (AS) among all risk categories and is the preferred treatment of choice in older patients. Bioprosthetic valve failure is an ongoing issue necessitating reoperations or valve-in-valve interventions. As redo-SAVR is related to elevated peri-procedural risks and mortality, valve-in-valve in-terventions are expected to increase in the future. What the study adds? Over the last decade, a steep increase in valve-in-valve procedures was observed, resulting in an incidence of 4% among TAVR procedures. Valve-in-valve interventions are feasible and showed lasting improvements in mean aortic valve gradients. No differences in technical and device successes or event-free survival between TAVR-in-SAVR and TAVR-in-TAVR could be observed. Introduction: Transcatheter aortic valve replacement (TAVR) has become a widely used, comparably efficient and safe alternative to surgical aortic valve replacement (SAVR). Its utilization continues to grow, especially among younger patients. Despite improvements in durability, degeneration and subsequent re-interventions of failed prosthetic valves are still common. Even though valve-in-valve procedures have become more frequent, little is known about the trends over time or about clinical and echocardiographic long-term outcomes. Materials and Methods: Patients who underwent a valve-in-valve procedure between December 2011 and December 2022 in a large tertiary university hospital were analyzed. Primary outcomes were defined as procedural and device successes as well as event-free survival. Secondary analyses between subsets of patients divided by index valve and date of procedure were performed. Results: Among 1407 procedures, 58 (4%) were valve-in-valve interventions, with an increased frequency observed over time. Overall, technical success was achieved in 88% and device success in 85% of patients. Complications were predominantly minor, with similar success rates among TAVR-in-SAVR (TiSAVR) and TAVR-in-TAVR (TiTAVR). Notably, there were significant and lasting improvements in mean echocardiographic gradients at 1 year. Event-free survival was 76% at one month and 69% at one year. Conclusions: Over the last decade, a rising trend of valve-in-valve procedures was observed. Despite an increase in procedures, complications show a contrasting decline with improved technical and device success over time. TiSAVR and TiTAVR showed comparable rates of procedural and device success as well as similar outcomes, highlighting the utility of valve-in-valve procedures in an aging population.