Data that Can Change TAVR and SAVR Strategy

In many relatively young patients with severe aortic stenosis, we rule out the idea of a mechanical valve, opting for a surgical aortic valve replacement (SAVR) with a bioprosthesis; we bet once the surgical bioprosthesis deteriorates, we will be able to solve it with transcatheter aortic valve replacement (TAVR) of the failed surgical valve: TAV-in-SAV. 

Data of this study recently published in JACC might challenge this idea. Technically speaking, treating a dysfunctional TAVR with redo TAVR (TAV-in-TAV) seems a lot simpler than treating a dysfunctional surgical valve with TAVR, with similar safety and mortality rates. 

These data support a new strategy: doing TAVR right from the start.  This idea stems from evidence on low risk, younger patients at long term follow up. When the valve deteriorates, we can redo TAVR.

Data from 434 patients undergoing TAV-in-TAV were compared against data from 624 undergoing TAV-in-SAV included in the multicenter registry Redo-TAVR international. Populations were matched using propensity score, leaving 165 patients with similar characteristics in each branch. 

Read also: Predilation in TAVR and Myocardial Injury.

Primary end point was procedural success, safety and mortality at 30 days and one year. 

TAV-in-TAV procedural success was achieved in 72.7% of patients vs 62.4% in TAV-in-SAV. This advantage of TAV-in-TAV was conducted by lower frequency of residual high valve gradient (p = 0.095), ectopic valve deployment (p = 0.081), coronary obstruction (p = 0.091), and conversion to open heart surgery (p=0.082).

Procedural safety was achieved in 70.3% of TAV-in-TAV vs. 72.1% TAV-in-SAV (p=0.715).

Mortality at 30 days resulted similar (3% vs 4.4%, p=0.57 respectively), as was mortality at one year (11.9% vs 10.2%, p=0.633). 

Read also: Diastolic Dysfunction and TAVR: Prognosis before and after Procedure.

The resulting valvular area was larger (1.55 ± 0.5 cm2 vs. 1.37 ± 0.5 cm2; p=0.040) and mean residual gradient was lower (12.6 ± 5.2 mm Hg vs. 14.9 ± 5.2 mm Hg; p=0.011) with TAV-in-TAV.

Moderate to severe aortic regurgitation was similar but mild regurgitation was more frequent with TAV-in-TAV (p=0.003).

Conclusion

This study comparing populations undergoing TAV-in-TAV vs TAV-in-SAV using propensity score matching showed similar safety and mortality but higher procedural success with TAV-in-TAV. 

Original Title: Transcatheter Replacement of Transcatheter Versus Surgically Implanted Aortic Valve Bioprostheses.

Reference: Uri Landes et al. J Am Coll Cardiol 2021;77:1–14 https://doi.org/10.1016/j.jacc.2020.10.053.

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