Failing Surgical Bioprosthesis: A Challenge on the Rise

Courtesy of Dr. Carlos Fava.

The gold standard for failing aortic bioprosthesis has traditionally been surgery. However, since the first valve in valve (TAV-in-SAV) report in 2007, by Wenaweser, transcatheter valve implantation has emerged as a valid alternative. Even so, at present there is not enough scientific evidence in this regard.

The present study analyzed 205 patients presenting failing aortic bioprosthesis. 126 (61.5%) were reoperated (redo-SAVR) and 798 received TAV-in-SAV.

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Those receiving TAV-in-SAV were older, had more comorbidities, more cardiac failure and had higher STS and EurosSCORE_log. After propensity score matching, the sample population was homogenized to 78 pares.

Mortality at 30 days and one year was numerically inferior in the TAV-in-SAV group, though it had no statistical significance (6.4% vs. 3.9% and 13.1% vs. 12.3%). Neither were there differences in stroke, AMI or need for definite pacemaker. The need for dialysis driven by acute kidney failure was numerically lower in the TAV-in-SAV group (11.5% vs. 3.8% p=0.13). Outcomes were similar across the population.

Hospitalization was lower in the TAV-in-SAV group (p=0.001).

Read also: “TAVR in Patients with Pure vs. Mixed Aortic Stenosis: Benefits and Evolution”.

Gradients at 30 days were higher in the TAV-in-SAV group (18.1 mmHg vs. 14.3 mmHg p=0.01). This was at the expense of the Edwards valves (21.3 mmHg gradient), not with the CoreValves (15.4 mmHg) that showed no difference with redo-SAVR. The presence of >20 mmHg gradient was twice as high with the Edwards compared against the CoreValve and redo-SAVR (51.9% vs. 22.6% and 17.1%).

Conclusion

Patients presenting failing aortic bioprosthesis due to severe aortic stenosis treated with redo-SAVR or TAV-in-SAV have similar evolution at 30 days and one year.

Commentary

This group currently presents a great challenge and is being researched at the moment.

This retrospective study showed similar evolution in both groups, but with less hospitalization days in the TAV-in-SAV. However, a nine-day hospital stay is still high.

It is important to choose the right transcatheter valve, since one of these presented higher post-implantation gradients. This will certainly improve with experience and the development of new devices.

Gentileza del Dr. Carlos Fava.

Original title: Transcatheter aortic valve implantation versus redo surgery for failing surgical aortic bioprostheses. A multicenter propensity score analysis.

Reference: Marco Spaziano, et al. EuroIntervention 2017;13:1149-1156.

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