Repeat Transcatheter Aortic Valve Replacement for Transcatheter Prosthesis Dysfunction

Surgical explantation of transcatheter aortic bioprosthesis: A systematic review and meta-analysis

Background

Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), aortic valve reintervention, particularly surgical TAVR valve explantation (TAVR explant), has not been well described.

Methods

MEDLINE, Embase, and Web of Science were searched through July 2021 to identify observational studies and case series reporting clinical outcomes of TAVR explant. Data on the frequency of TAVR explant, patient demographic characteristics, clinical indications, operative data, and perioperative outcomes were extracted. Study-specific estimates were combined using one-group meta-analysis in a random-effects model.

Results

A total of 10 studies were identified that included 1690 patients undergoing a TAVR explant. The frequency of TAVR explant among TAVR recipients was 0.4% (95% confidence interval [CI], 0.2%-0.6%). The mean patient age was 73.7 years (95% CI, 72.9-74.6 years). The mean Society of Thoracic Surgeons predicted risk of mortality was 5.9% (95% CI, 2.9%-8.8%) at the index TAVR and 8.1% (95% CI, 5.4%-10.8%) at TAVR explant. The mean time from implant to explant was 345.0 days (95% CI, 196.7-493.3 days). Among patients with documented device type, 59.8% (95% CI, 43.5%-76.0%) had a balloon-expandable valve and 40.2% (95% CI, 24.0%-56.5%) had a self-expandable valve. Concomitant procedures during TAVR explant were performed in 52.9% of patients (95% CI, 33.8%-72.0%), and the most common concomitant procedure was aortic repair (28.5%; 95% CI, 14.0%-42.9%). The 30-day mortality after TAVR explant was 16.7% (95% CI, 12.2%-21.2%).

Conclusions

TAVR explant in patients with a failing TAVR appears to be rare; however, the clinical impact of TAVR explant is substantial. Implanters must be mindful of the need for a lifetime management strategy in younger and lower-risk patients when choosing the valve type for the initial procedure.

The Use of BASILICA Technique to Prevent Coronary Obstruction in a TAVI-TAVI Procedure

Transcatheter aortic valve implantation (TAVI) to manage structural bioprosthetic valve deterioration has been successful in mitigating the risk of a redo cardiac surgery. However, TAVI-in-TAVI is a complex intervention, potentially associated with feared complications such as coronary artery obstruction. Coronary obstruction risk is especially high when the previously implanted prosthesis had supra-annular leaflets and/or the distance between the prosthesis and the coronary ostia is short. The BASILICA technique (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) was developed to prevent coronary obstruction during native or valve-in-valve interventions but has now also been considered for TAVI-in-TAVI interventions. Despite its utility, the technique requires a not so widely available toolbox. Herein, we discuss the TAVI-in-TAVI BASILICA technique and how to perform it using more widely available tools, which could spread its use.

Non-Aortic Valve Cardiac Surgery after Transcatheter Aortic Valve Replacement

BACKGROUND

Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), the frequency and outcomes of non-aortic valve cardiac surgery after TAVR are unknown.

METHODS

Non-aortic valve surgery after TAVR from 2011 to 2019 was queried using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. A total of 666 patients, including 47 (7.1%) unplanned TAVR-explant and 3 (0.5%) aborted procedures during non-aortic valve procedures, were identified.

RESULTS

These 666 procedures were performed by 459 surgeons (median 1.0 case per surgeon) from 308 centers (median 1.0 case per center), which represents 29% of Database participants. The case number increased over time from 4 in 2011 to 204 in 2019, largely attributable to coronary artery bypass grafting (CABG) (n=283; 42.5%) and mitral (n=258; 38.7%) procedures. The median age was 75.0 and 51.4% had previous cardiac surgeries. The 30-day mortality of the entire cohort was 17.0%. Subgroups with particularly high mortality included patients with robot-assisted mitral surgery (n=5/12; 41.7%), unplanned TAVR-explant (n=19/47; 40.4%), open atrial transcatheter mitral valve replacement (n=10/33; 30.3%) and aortic repair (n=24/79; 29.8%). Among 390 patients with available STS predicted risk of mortality, the 30-day mortality with isolated CABG, isolated mitral repair/replacement and the entire group was 8.4% (n=19/225), 13.5% (n=21/155) and 10.8% (n=42/390) with corresponding observed-to-expected mortality (O/E) ratio of 1.8, 1.8 and 1.7, respectively.

CONCLUSIONS

Non-aortic valve operation after TAVR was associated with a high mortality and O/E ratio. Implanters must be mindful of "lifetime management" strategy including assessment of concurrent pathologies during TAVR candidate selection.

Repeat transcatheter aortic valve implantation and implications for transcatheter heart valve performance: insights from bench testing

BACKGROUND

THV implantation within failed surgical valves is well established. However, the implications of THV implantation within failed THVs are poorly understood.

AIMS

This study aimed to assess the impact of different transcatheter heart valve (THV) designs and implant positioning strategies on hydrodynamic performance after redo transcatheter aortic valve implantation (TAVI).

METHODS

THVs of varying design (SAPIEN 3, Evolut PRO, ACURATE neo, ALLEGRA, and Portico) and size were implanted inside SAPIEN XT and Evolut R THVs. Hydrodynamic function as per International Organization for Standardization (ISO) specifications was evaluated using a pulse duplicator, and multi-modality imaging was performed.

RESULTS

The majority of tested THV-in-THV combinations resulted in stable anchoring of the new implant. However, some combinations resulted in unstable anchoring with the potential for dislodgement or embolisation. Hydrodynamic function was favourable for all tested THV designs implanted in the intra-annular SAPIEN XT THV. SAPIEN 3 implantation within an Evolut THV with supra-annular leaflets must be appropriately sized to ensure adequate anchoring. Avoidance of an intra-annular deployment mitigated leaflet overhang of the Evolut leaflets and optimised hydrodynamic performance.

CONCLUSIONS

This study demonstrates that most THV designs and implantation strategies can result in favourable hydrodynamic performance following redo TAVI. Whether the leaflets of a failed THV are intra- or supra-annular may have important implications for the positioning of a redo-THV implant. Certain THV designs or implantation positions may be more desirable when performing redo TAVI.

Transcatheter solutions for transcatheter aortic valve replacement dysfunction: is redo transcatheter aortic valve replacement a durable option?

As transcatheter aortic valve replacement (TAVR) expands into a younger and lower risk cohort of patients, many important clinical questions are raised, including the one of overall valve durability. Bioprosthetic valve dysfunction (BVD) is a complex clinical issue, of which structural valve deterioration (SVD) is a subcategory. Similar to surgical bioprosthesis, transcatheter heart valves (THVs) can fail over the years however, data on long-term THVs durability is lacking, especially in the lower risk cohort. Surgical explant with open aortic surgery or a second THV, described as redo-TAVR, are feasible options when the first THV fails. However long-term data in these patients is even more limited. Important clinical considerations such as the mechanism(s) of THV dysfunction, the type and timing of the second procedure must be carefully considered. There are also inherently important clinical concerns regarding redo-TAVR, such as coronary access and higher post procedure gradients. In the present keynote lecture, we review the diagnosis of THV dysfunction and transcatheter options available when SVD occurs.

Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database

OBJECTIVES

To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice.

DESIGN

Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed.

SETTING

27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis.

PARTICIPANTS

31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG.

RESULTS

In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60-75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes.

CONCLUSIONS

Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Transcatheter aortic valve replacement for structural degeneration of previously implanted transcatheter valves (TAVR-in-TAVR): a systematic review

OBJECTIVES

Transcatheter aortic valve replacement (TAVR) represents a valid treatment for patients with aortic valve stenosis and high or intermediate surgical risk. However, biological transcatheter valves can also experience a structural degeneration after years, and a redo-TAVR procedure (TAVR-in-TAVR) can be a valid option. We revised the current available literature for indications, procedural and technical details and outcome on TAVR-in-TAVR procedures for degenerated TAVR valves.

METHODS

A systematic search was conducted in the public medical database for scientific articles on TAVR-in-TAVR procedures for degenerated transcatheter valves. Data on demographics, indications, first and second transcatheter valve type and size, mortality, complications and follow-up were extracted and analysed.

RESULTS

A total of 13 studies (1 multicentre, 3 case series, 9 case reports) were included in this review, with a total amount of 160 patients treated with TAVR-in-TAVR procedures for transcatheter valve failure. The mean age was 74.8 ± 7.8 with 84 males (52.8%). The mean elapsed time from the first TAVR procedure was 58.1 ± 23.4 months. Main indication for TAVR-in-TAVR was pure stenosis (38.4%, with mean gradient of 44.5 ± 18.5 mmHg), regurgitation (31.4%), mixed stenosis and regurgitation (29.5%) and leaflet thrombosis (8.8%). Procedural success rate was 86.8%, with second TAVR valve malposition occurred in 4 cases (2.5%). The hospital mortality rate was 1.25% (2/160). Post-procedural echocardiographic control showed moderate regurgitation in 5.6% of patients (9/160) and residual transvalvular mean gradient ≥20 mmHg in 5% of cases. Postoperative complications included major vascular complications (8.7%), new pacemaker implantation (8.7%), acute kidney failure (3.7%), stroke (0.6%) and coronary obstruction (0.6%). The mean follow-up time was 6 ± 5.6 months with 1 non-cardiovascular death reported.

CONCLUSIONS

TAVR-in-TAVR represents a valid alternative to standard surgery for the treatment of degenerated transcatheter valves in high-risk patients. Despite these promising results, further studies are required to assess durability and haemodynamic performances of the second TAVR valve.

SUBJ COLLECTION

117, 122, 125.

Aortic and mitral bioprosthetic valve dysfunction: surgical or percutaneous solutions?

In the last years, there has been a trend to prefer biological prostheses, especially among young patients, with the aim to avoid anticoagulant treatment. Surgical tissue valves have so far demonstrated their solid long-term durability. However, younger age has been identified as one of the main risk factors for developing structural valve deterioration (SVD). As a consequence, the proportion of subjects at risk for valve dysfunction will constantly rise in the near future. However, while surgical reintervention has always been considered the gold standard for treatment of prosthesis deterioration, the introduction of transcatheter heart valves could offer new therapeutical options, particularly among high-risk patients, aiming a second less invasive chance. The recent standardization of valve durability definitions will soon allow a more comprehensive understanding of the mechanism underlying SVD and guide the choice of prosthesis for patients needing valve replacement.

Early Leaflet Thickening, Durability and Bioprosthetic Valve Failure in TAVR

All bioprosthetic valves, both surgical and transcatheter, have a finite lifespan before their leaflets inevitably degenerate, leading to stenosis or regurgitation. As younger, low-risk patients receive a transcatheter aortic valve, it is expected that they will most likely outlive their bioprosthetic valve. The heterogeneity of studies regarding surgical valve durability makes the interpretation of the data challenging. Leaflet thickening is seen in transcatheter heart valves but currently there is no evidence that it leads to premature valve deterioration or clinical events. Standardized definitions of structural valve deterioration should allow for comparisons between future clinical trials to assess the durability of different transcatheter heart valves.

Asymptomatic severe aortic stenosis, bicuspid aortic valves and moderate aortic stenosis in heart failure: New indications for transcatheter aortic valve implantation

Aortic stenosis (AS) remains one of the most common valvular heart diseases, with enormous impact on patient survival. Over the past years, transcatheter aortic valve implantation (TAVI) has become a reality worldwide, offering a less invasive method to treat AS. Apart from the classical indications for aortic valve disease, recent studies tried to address unanswered questions for TAVI - asymptomatic severe AS, bicuspid aortic valves and moderate AS in patients with heart failure. This review discusses the rationale of those possible indications, pitfalls and current evidence in the medical literature.

5 Year Outcomes of Patients With Aortic Structural Valve Deterioration Treated With Transcatheter Valve in Valve - A Single Center Prospective Registry

The Valve-in-Valve (ViV) technique is an established alternative for the treatment of structural bioprosthetic valve deterioration (SVD). Data describing the intermediate term follow up of patients treated with this approach is scarce. We report on our intermediate-term outcomes of patients with SVD in the Aortic position treated with ViV. Included were patients with symptomatic SVD in the aortic position valve who were treated by Valve in valve transcatheter aortic valve implantation (ViV-TAVI) during the years 2010-2019 in our center. Three main outcomes were examined during the follow up period: NYHA functional class, ViV-TAVI hemodynamic per echocardiography, and mortality. Our cohort consisted of 85 patients (mean age 78.8 ± 8.9 years). The indications for aortic ViV were: SVD isolated aortic stenosis in 37.6%, SVD isolated aortic regurgitation in 42.2% and combined valve pathology in 20.0%. Self-expandable and balloon-expandable devices were used in 73 (85.9%) and 12 (14.1%), respectively. Average follow up was 3.7 ± 2.4 years. 95 and 91% of patients were in NYHA functional class I/II at 1 and 5 year follow up respectively. At one year, the mean trans-aortic valve pressure was 15 ± 9 mmHg and rates of ≥ moderate aortic regurgitation were 3.7%. Mortality at one year was 8.6% (95% CI 2.3–14.4) and 31% (95% CI 16.5–42.5) at 5 years. ViV in the aortic position offers an effective and durable treatment option for patient with SVD, with low rates of all-cause mortality, excellent hemodynamic and improved functional capacity at intermediate follow up.

Surgical Explantation After TAVR Failure: Mid-Term Outcomes From the EXPLANT-TAVR International Registry

OBJECTIVES

The aim of this study was to evaluate clinical characteristics, mechanisms of failure, and outcomes of transcatheter aortic valve replacement (TAVR) explantation.

BACKGROUND

Surgical explantation following TAVR may be required for structural valve degeneration, paravalvular leak, infection, or other reasons. However, in-depth data on indications and outcomes are lacking.

METHODS

Data from a multicenter, international registry (EXPLANT-TAVR) of patients who underwent TAVR explantation were reviewed retrospectively. Explantations performed during the same admission as initial TAVR were excluded. Clinical and echocardiographic outcomes were evaluated. Median follow-up duration was 6.7 months (interquartile range [IQR]: 1.0-18.8 months) after TAVR explantation and was 97.7% complete at 30 days and 86.1% complete at 1 year.

RESULTS

From November 2009 to September 2020, 269 patients across 42 centers with a mean age of 72.7 ± 10.4 years underwent TAVR explantation. About one quarter (25.9%) were deemed low surgical risk at index TAVR, and median Society of Thoracic Surgeons risk at TAVR explantation was 5.6% (IQR: 3.2%-9.6%). The median time to explantation was 11.5 months (IQR: 4.0-32.4 months). Balloon-expandable and self-expanding or mechanically expandable valves accounted for 50.9% and 49.1%, respectively. Indications for explantation included endocarditis (43.1%), structural valve degeneration (20.1%), paravalvular leak (18.2%), and prosthesis-patient mismatch (10.8%). Redo TAVR was not feasible because of unfavorable anatomy in 26.8% of patients. Urgent or emergency cases were performed in 53.1% of patients, aortic root replacement in 13.4%, and 54.6% had concomitant cardiac procedures. Overall survival at last follow-up was 76.1%. In-hospital, 30-day, and 1-year mortality rates were 11.9%, 13.1%, and 28.5%, respectively, and stroke rates were 5.9%, 8.6%, and 18.7%, respectively.

CONCLUSIONS

The EXPLANT-TAVR registry reveals that surgical risks associated with TAVR explantation are not negligible and should be taken into consideration in the lifetime management of aortic stenosis.

Redo-transcatheter aortic valve replacement with the supra-annular, self-expandable Evolut platform: Insights from the Transcatheter valve Therapy Registry

OBJECTIVES

To assess the safety profile of redo-TAVR procedures from patients in the transcatheter valve therapy (TVT) Registry.

BACKGROUND

The use of transcatheter aortic valves (TAV) to treat previously implanted failing TAVS (TAV-in-TAV) has been an increasingly important topic as indications for TAVR move to younger and lower-risk patients, but data on the safety and efficacy of redo-TAVR is limited.

METHODS

Patients undergoing redo-TAVR procedures using the Evolut R, Evolut PRO or Evolut PRO+ valve in the TVT Registry between April 2015 and March 2020 were included. In-hospital, 30-day and 1-year outcomes were analyzed.

RESULTS

Redo-TAVR was performed in 292 patients (213 patients received the Evolut R valve and 79 received the Evolut PRO or PRO+ valve). Device success was achieved in 94.5%. In-hospital mortality was 2.1%, stroke occurred in 2.7%, and 77.2% of patients were discharged home. There were no cases of coronary compression/obstruction or myocardial infarction that occurred in index hospitalization. Mean gradient at 30-days was 11.9 ± 6.9 mmHg, and 73.1% had none/trace total aortic regurgitation.

CONCLUSIONS

Results from the TVT Registry demonstrate good short-term outcomes after redo-TAVR with the supra-annular, self-expandable Evolut platform. Long-term follow-up is necessary to further expand understanding this complex scenario.

Aortic valve reintervention in patients with failing transcatheter aortic bioprostheses: A statewide experience

BACKGROUND

Despite the rapid adoption of transcatheter aortic valve replacement since its approval, the frequency and outcomes of aortic valve reintervention after transcatheter aortic valve replacement are poorly understood.

METHODS

Valve reinterventions, either surgical transcatheter aortic valve replacement valve explantation or repeat transcatheter aortic valve replacement, between 2012 and 2019 were queried using the Society of Thoracic Surgeons Database and the Transcatheter Valve Therapy Registry through the Michigan Statewide quality collaborative. The reintervention frequency and clinical outcomes including observed-to-expected mortality ratio using Society of Thoracic Surgeons Predicted Risk of Mortality were reviewed.

RESULTS

Among 9694 transcatheter aortic valve replacement recipients, a total of 87 patients (0.90%) received a reintervention, consisting of 34 transcatheter aortic valve replacement explants and 53 repeat transcatheter aortic valve replacement procedures. The transcatheter aortic valve replacement explant group demonstrated a higher Society of Thoracic Surgeons Predicted Risk of Mortality. Reintervention cases increased from 0 in 2012 and 2013 to 26 in 2019. The proportion of transcatheter aortic valve replacement explants among all reinterventions increased and was 65% in 2019. Self-expandable devices had a higher reintervention rate than balloon-expandable devices secondary to a higher transcatheter aortic valve replacement explant frequency (0.58% [23/3957] vs 0.19% [11/5737]; P = .001), whereas repeat transcatheter aortic valve replacement rates were similar (0.61% [24/3957] vs 0.51% [29/5737]; P = .51). Among patients with transcatheter aortic valve replacement explants, contraindications to repeat transcatheter aortic valve replacement included unfavorable anatomy (75%), need for other cardiac surgery (29%), other structural issues by transcatheter aortic valve replacement device (18%), and endocarditis (12%). For transcatheter aortic valve replacement explant and repeat transcatheter aortic valve replacement, the 30-day mortality was 15% and 2% (P = .032) and the observed-to-expected mortality ratio was 1.8 and 0.3 (P = .018), respectively.

CONCLUSIONS

Aortic valve reintervention remains rare but is increasing. The clinical impact of transcatheter aortic valve replacement explant was substantial, and the proportion of transcatheter aortic valve replacement explants was significantly higher in patients with a self-expandable device.

Transcatheter Valve-in-Valve Procedures for Bioprosthetic Valve Dysfunction in Patients With Rheumatic vs. Non-Rheumatic Valvular Heart Disease

Background: Bioprosthetic heart valve has limited durability and lower long-term performance especially in rheumatic heart disease (RHD) patients that are often subject to multiple redo operations. Minimally invasive procedures, such as transcatheter valve-in-valve (ViV) implantation, may offer an attractive alternative, although data is lacking. The aim of this study was to evaluate the baseline characteristics and clinical outcomes in rheumatic vs. non-rheumatic patients undergoing ViV procedures for severe bioprosthetic valve dysfunction.

Methods: Single center, prospective study, including consecutive patients undergoing transcatheter ViV implantation in aortic, mitral and tricuspid position, from May 2015 to September 2020. RHD was defined according to clinical history, previous echocardiographic and surgical findings.

Results: Among 106 patients included, 69 had rheumatic etiology and 37 were non-rheumatic. Rheumatic patients had higher incidence of female sex (73.9 vs. 43.2%, respectively; p = 0.004), atrial fibrillation (82.6 vs. 45.9%, respectively; p < 0.001), and 2 or more prior surgeries (68.1 vs. 32.4%, respectively; p = 0.001). Although, device success was similar between groups (75.4 vs. 89.2% in rheumatic vs. non-rheumatic, respectively; p = 0.148), there was a trend toward higher 30-day mortality rates in the rheumatic patients (21.7 vs. 5.4%, respectively; p = 0.057). Still, at median follow-up of 20.7 [5.1–30.4] months, cumulative mortality was similar between both groups (p = 0.779).

Conclusion: Transcatheter ViV implantation is an acceptable alternative to redo operations in the treatment of patients with RHD and severe bioprosthetic valve dysfunction. Despite similar device success rates, rheumatic patients present higher 30-day mortality rates with good mid-term clinical outcomes. Future studies with a larger number of patients and follow-up are still warranted, to firmly conclude on the role transcatheter ViV procedures in the RHD population.

Evaluation of structural valve deterioration and bioprosthetic valve failure utilizing the new European consensus definition in patients undergoing TAVI with first-generation devices: Outcomes beyond 5 years from a single center in Turkey

OBJECTIVE

The long-term durability of transcatheter aortic bioprosthetic valves continues to be a major concern. Standardized criteria of the structural valve deterioration (SVD) and bioprosthetic valve failure (BVF) have recently been defined. Limited studies have evaluated the long-term durability of transcatheter aortic valve implantation (TAVI) according to these new definitions. We aim to analyze the durability of TAVI beyond 5 years and to report the frequency of SVD and BVF.

METHODS

A total of 89 patients who had undergone TAVI and had theoretically completed at least 5 years after the procedure were included. Either a Medtronic CoreValve or an Edwards SAPIEN XT valve were implanted in the patients. New standardized definitions were used to evaluate SVD and BVF.

RESULTS

The mean age of the patients was 78.70±6.95 years. SVD occured in 4 (4.5%) patients during 6 years of follow-up. Severe SVD was observed in 2 patients (2.2%), and these patients had the New York Heart Association class II symptoms. Both patients with severe SVD also met the criteria of BVF. Moderate SVD was observed in 2 patients (2.2%), and these patients had no valve-related symptoms. Of the 4 SVD cases, 2 were associated with increased mean transaortic gradients, whereas the remaining 2 cases were associated with intraprosthetic aortic regurgitation. All patients with SVD are still alive, and none of them have required aortic valve reintervention.

CONCLUSION

Although first-generation TAVI devices were used, we determined the low rate of SVD and BVF at the 6-year follow-up. It may be suggested that there is no major concern associated with TAVI even with first-generation devices regarding long-term durability.

Nationally Representative Repeat Transcatheter Aortic Valve Replacement Outcomes: Report From the Centers for Medicare and Medicaid Services

OBJECTIVES

The aim of this study was to examine real-world experience with repeat transcatheter aortic valve replacement (TAVR) in a population-based national database.

BACKGROUND

Repeat TAVR is a growing option in patients requiring reintervention for TAVR. However, large-scale studies with longitudinal follow-up are limited.

METHODS

All Medicare beneficiaries who underwent TAVR from 2012 to 2017 were included. Outcomes included 30-day and longitudinal mortality and major adverse cardiovascular events, defined as death, stroke, pacemaker insertion, major bleeding, acute kidney injury, or cardiac arrest. Outcomes of repeat TAVR were compared with surgical explantation after TAVR (TAVR explantation) in a matched analysis.

RESULTS

Of 133,250 patients who underwent TAVR, 617 (0.46%) underwent subsequent repeat TAVR at a median interval of 154 days (interquartile range: 58-537 days). Mortality at 30 days and 1 year was 6.0% and 22.0%, respectively. Rates of 30-day stroke and pacemaker insertion were 1.8% and 4.2%. Mortality at 30 days was lower in those who underwent their first TAVR during the later era (2015-2017) compared with earlier years (2012-2014) (4.6% vs 8.7%; P = 0.049). Repeat TAVR was associated with lower 30-day mortality compared with a matched group undergoing TAVR explantation (6.2% vs 12.3%; P = 0.05), although 1-year mortality was similar (21.0% vs 20.8%; P = 1.000). The incidence of 30-day major adverse cardiovascular events was higher with TAVR explantation compared with repeat TAVR (risk ratio: 2.92; 95% CI: 1.88-4.99; P ≤ 0.001).

CONCLUSIONS

Repeat TAVR was performed with acceptable 30-day mortality in this high-risk population. Short-term outcomes were superior to surgical explantation, but 1-year outcomes were similar. Repeat TAVR will likely be an important option for aortic valve reintervention after TAVR.

Incidence, Causes, and Outcomes Associated With Urgent Implantation of a Supplementary Valve During Transcatheter Aortic Valve Replacement

Importance

Transcatheter aortic valve replacement (TAVR) failure is often managed by an urgent implantation of a supplementary valve during the procedure (2-valve TAVR [2V-TAVR]). Little is known about the factors associated with or sequelae of 2V-TAVR.

Objective

To examine the incidence, causes, and outcomes of 2V-TAVR.

Design, Setting, and Participants

A retrospective cohort study was performed using data from an international registry of 21 298 TAVR procedures performed from January 1, 2014, through February 28, 2019. Among the 21 298 patients undergoing TAVR, 223 patients (1.0%) undergoing 2V-TAVR were identified. Patient-level data were available for all the patients undergoing 2V-TAVR and for 12 052 patients (56.6%) undergoing 1V-TAVR. After excluding patients with missing 30-day follow-up or data inconsistencies, 213 2V-TAVR and 10 010 1V-TAVR patients were studied. The 2V-TAVR patients were compared against control TAVR patients undergoing a 1-valve TAVR (1V-TAVR) using 1:4 17 propensity score matching. Final analysis included 1065 (213:852) patients.

Exposures

Urgent implantation of a supplementary valve during TAVR.

Main Outcomes and Measures

Mortality at 30 days and 1 year.

Results

The 213 patients undergoing 2V-TAVR had similar age (mean [SD], 81.3 [0.5] years) and sex (110 [51.6%] female) as the 10 010 patients undergoing 1V-TAVR (mean [SD] age, 81.2 [0.5] years; 110 [51.6%] female). The 2V-TAVR incidence decreased from 2.9% in 2014 to 1.0% in 2018 and was similar between repositionable and nonrepositionable valves. Bicuspid aortic valve (odds ratio [OR], 2.20; 95% CI, 1.17-4.15; P = .02), aortic regurgitation of moderate or greater severity (OR, 2.02; 95% CI, 1.49-2.73; P < .001), atrial fibrillation (OR, 1.43; 95% CI, 1.07-1.93; P = .02), alternative access (OR, 2.59; 95% CI, 1.72-3.89; P < .001), early-generation valve (OR, 2.32; 95% CI, 1.69-3.19; P < .001), and self-expandable valve (OR, 1.69; 95% CI, 1.17-2.43; P = .004) were associated with higher 2V-TAVR risk. In 165 patients (80%), the supplementary valve was implanted because of residual aortic regurgitation after primary valve malposition (94 [46.4%] too high and 71 [34.2%] too low). In the matched 2V-TAVR vs 1V-TAVR cohorts, the rate of device success was 147 (70.4%) vs 783 (92.2%) (P < .001), the rate of coronary obstruction was 5 (2.3%) vs 3 (0.4%) (P = .10), stroke rate was 9 (4.6%) vs 13 (1.6%) (P = .09), major bleeding rates were 25 (11.8%) vs 46 (5.5%) (P = .03) and annular rupture rate was 7 (3.3%) vs 3 (0.4%) (P = .03). The hazard ratios for mortality were 2.58 (95% CI, 1.04-6.45; P = .04) at 30 days, 1.45 (95% CI, 0.84-2.51; P = .18) at 1 year, and 1.20 (95% CI, 0.77-1.88; P = .42) at 2 years. Nontransfemoral access and certain periprocedural complications were independently associated with higher risk of death 1 year after 2V-TAVR.

Conclusions and Relevance

In this cohort study, valve malposition was the most common indication for 2V-TAVR. Incidence decreased over time and was low overall, although patients with a bicuspid or regurgitant aortic valve, nontransfemoral access, and early-generation or self-expandable valve were at higher risk. These findings suggest that compared with 1V-TAVR, 2V-TAVR is associated with high burden of complications and mortality at 30 days but not at 1 year.

Antithrombotic Therapy After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a treatment option for symptomatic patients with severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. However, TAVR carries a risk for thrombotic and bleeding events, underscoring the importance of defining the optimal adjuvant antithrombotic regimen. Antithrombotic considerations are convoluted by the fact that many patients undergoing TAVR are generally elderly and present with multiple comorbidities, including conditions that may require long-term oral anticoagulation (OAC) (eg, atrial fibrillation) and antiplatelet therapy (eg, coronary artery disease). After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy to be associated with an increased risk for bleeding events, particularly early postprocedure, compared with single-antiplatelet therapy with aspirin. Concerns surrounding the potential for thrombotic complications have raised the hypothesis of adjunctive use of OAC for patients with no baseline indications for anticoagulation. Although effective in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with atrial fibrillation, the adjunctive use of antiplatelet therapy increases bleeding. Whether direct oral anticoagulant agents achieve better outcomes than vitamin K antagonists remains under investigation. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation. The aim of the present review is to appraise the current published research and recommendations surrounding the management of antithrombotic therapy after TAVR, with perspectives on evolving paradigms and ongoing trials.

Left atrial appendage thrombus and cerebrovascular events post-transcatheter aortic valve implantation

AIMS

To elucidate the frequency and clinical impact of left atrial appendage thrombus (LAAT) in patients set for transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

All patients undergoing TAVI between January 2014 and June 2020 with analysable multislice computed tomography (MSCT) for LAAT were included. Baseline and procedural characteristics were collected, pre-procedural MSCT's were retrospectively analysed for LAAT presence. The primary endpoint was defined as the cumulative incidence of any cerebrovascular event (stroke or transient ischaemic attack) within the first year after TAVI. A Cox proportional hazards model was used to identify predictors.A total of 1050 cases had analysable MSCT. Median age was 80 [interquartile range (IQR) 74-84], median Society of Thoracic Surgeons' Predicted Risk Of Mortality (STS-PROM) was 3.4% (IQR 2.3-5.5). Thirty-six percent were on oral anticoagulant therapy for atrial fibrillation (AF). LAAT was present in 48 (4.6%) of cases. Patients with LAAT were at higher operative risk [STS-PROM: 4.9% (2.9-7.1) vs. 3.4% (2.3-5.5), P = 0.01], had worse systolic left ventricular function [EF 52% (35-60) vs. 55% (45-65), P = 0.01] and more permanent pacemakers at baseline (35% vs. 10%, P < 0.01). All patients with LAAT had a history of AF and patients with LAAT were more often on vitamin K antagonist-treatment than patients without LAAT [43/47 (91%) vs. 232/329 (71%), P < 0.01]. LAAT [hazard ratio (HR) 2.94 (1.39-6.22), P < 0.01] and the implantation of more than one valve [HR 4.52 (1.79-11.25), P < 0.01] were independent predictors for cerebrovascular events.

CONCLUSION

Patients with MSCT-identified LAAT were at higher risk for cerebrovascular events during the first year after TAVI.

Timing of Intervention in Asymptomatic Aortic Stenosis

The decision to perform an intervention for asymptomatic severe aortic stenosis (AS) requires careful weighing of the risks of early intervention against those of watchful observation, and the optimal timing of intervention remains controversial. With improvements in surgical and postoperative care, long-term survival after surgical aortic valve (AV) replacement (AVR) is excellent in low-risk patients, and the emergence of transcatheter AVR may change the thresholds for early preemptive intervention, although a durability issue has to be resolved. A watchful observation strategy also has a risk of sudden death, irreversible myocardial damage, and increase in operative risk while waiting for symptoms to develop. We have been waiting for a prospective randomized trial to solve the intense debate between early AVR and watchful observation, and the RECOVERY (Randomized Comparison of Early Surgery versus Conventional Treatment in Very Severe Aortic Stenosis) trial provides the evidence to support early AVR for asymptomatic severe AS. Risk assessment with severity of AS and staging classification may help to facilitate the identification of patients who may benefit from early intervention. Based on the results of the RECOVERY trial, early surgical AVR is reasonable for asymptomatic patients with very severe AS (aortic jet velocity ≥4.5 m/s) and low surgical risk. Further evidence is required to extend the indications of surgical AVR and to consider transcatheter AVR in asymptomatic patients with severe AS.

Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-Risk Patients With Severe Aortic Stenosis

Transcatheter aortic valve replacement (TAVR) is approved for all patient risk profiles and is an option for all patients irrespective of age. However, patients enrolled in the low- and intermediate-risk trials were in their 70s, and those in the high-risk trials were in their 80s. TAVR has never been systematically tested in young (<65 years), low-risk patients. Unanswered questions remain, including the safety and effectiveness of TAVR in patients with bicuspid aortic valves; future coronary access; durability of transcatheter heart valves; technical considerations for surgical transcatheter heart valve explantation; management of concomitant conditions such as aortopathy, mitral valve disease, and coronary artery disease; and the safety and feasibility of future TAVR-in-TAVR. The authors predict that balancing these questions with patients' clear preference for less invasive treatment will become common. In this paper, the authors consider each of these questions and discuss risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe aortic stenosis.

Transcatheter Aortic Valve Replacement for Degenerated Transcatheter Aortic Valves: The TRANSIT International Project

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has determined a paradigm shift in the treatment of patients with severe aortic stenosis. However, the durability of bioprostheses is still a matter of concern, and little is known about the management of degenerated TAV. We sought to evaluate the outcomes of patients with a degenerated TAV treated by means of a second TAVR.

METHODS

The TRANSIT is an international registry that included cases of degenerated TAVR from 28 centers. Among around 40 000 patients treated with TAVR in the participating centers, 172 underwent a second TAVR: 57 (33%) for a mainly stenotic degenerated TAV, 97 (56%) for a mainly regurgitant TAV, and 18 (11%) for a combined degeneration. Overall, the rate of New York Heart Association class III/IV at presentation was 73.5%.

RESULTS

Valve Academic Research Consortium 2 device success rate was 79%, as a consequence of residual gradient (14%) or regurgitation (7%). At 1 month, the overall mortality rate was 2.9%, while rates of new hospitalization and New York Heart Association class III/IV were 3.6% and 7%, respectively, without significant difference across the groups. At 1 year, the overall mortality rate was 10%, while rates of new hospitalization and New York Heart Association class III/IV were 7.6% and 5.8%, respectively, without significant difference across the groups. No cases of valve thrombosis were recorded.

CONCLUSIONS

Selected patients with a degenerated TAV may be safely and successfully treated by means of a second TAVR. This finding is of crucial importance for the adoption of the TAVR technology in a lower risk and younger population.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04500964.

A case report of open-aorta, direct transcatheter valve-in-valve implantation: an innovative approach to manage the hazard of coronary flow compromise in transcatheter aortic valve re-interventions

Background

Coronary flow compromise is a significant risk of transcatheter aortic valve therapy. Warranting preservation of coronary flow is even more challenging with transcatheter aortic valve re-intervention since the implantation of a transcatheter valve within a degenerated bioprosthetic or transcatheter valve increases significantly this hazard.

Case summary

We present a case of heart failure secondary to transcatheter aortic valve degeneration requiring a transcatheter aortic valve re-intervention. Pre-operative imaging studies demonstrated a high risk for iatrogenic coronary flow impairment. The patient underwent a successful surgical removal of the prosthetic valve leaflets followed by direct transcatheter aortic valve implantation.

Conclusion

We reviewed the literature on the approach to difficult coronaries in transcatheter aortic valve therapy, and we describe an innovative hybrid approach that may represent a viable alternative in cases where catheter techniques of coronary flow preservation are not applicable.

Bailout From Sinus Jailing: In-Series TAVR-in-TAVR to Avoid Coronary Flow Obstruction

Redo transcatheter aortic valve replacement (TAVR) may pose the risk of coronary flow obstruction. We report 2 cases of severe TAVR regurgitation due to different physiopathological mechanisms in which TAVR-in-TAVR could be at high risk for sinus sequestration. Both cases were successfully treated by in-series implantation of a second transcatheter heart valve, thus avoiding sinus sequestration. (Level of Difficulty: Intermediate.).

Acute Presentation of Structural Valve Degeneration in a Transcatheter Heart Valve (Sapien XT) at 7.5 Years; Successful Redo TAVR With a Sapien 3 Ultra

Little is known about the presentation of structural valve degeneration complicating transcatheter heart valves (THVs). We report a case of acute heart failure, secondary to leaflet prolapse, in a previously well 77-year-old man, 7.5 years after successful transcatheter aortic valve replacement with a 26-mm balloon-expandable Sapien XT (Edwards Lifesciences, Irvine, CA) THV. This case highlights that structural valve degeneration complicating THVs might lead to acute presentation with little warning from previous echocardiograms. Calcification might be absent on imaging. Redo transcatheter aortic valve replacement is feasible and appears safe. Post deployment optimization with a highly noncompliant balloon might improve full expansion of the newly implanted THV and improve valve performance.

Surgical Explantation of Transcatheter Aortic Valve Bioprostheses: A Statewide Experience

[Figure: see text].

Transcatheter Aortic Valve Replacement for a Degenerated Transcatheter Valve-A Single Center Experience

BACKGROUND

 The transcatheter valve-in-valve treatment (TAV-in-TAV) of degenerated transcatheter aortic valves is becoming more relevant, as the use of transcatheter aortic valve replacement (TAVR) increases. We report our experience with TAV-in-TAV in patients with a degenerated transcatheter heart valve (THV).

METHODS

 We retrospectively analyzed prospectively collected data from our designated TAVR database. Intraprocedural and intrahospital outcomes were reported.

RESULTS

 Ten patients out of a total of 3,144 TAVR implantations since 2007 presented with a degenerated THV, among those six with an Edwards Sapien XT (Edwards Lifesciences, Irvine, California, United States) valve, treated with a Medtronic Evolut R (Medtronic, Dublin, Ireland) valve. Four patients had severe stenosis, one pure insufficiency, and five combined stenosis and insufficiency. Average time between initial implantation and re-intervention was 6.8 ± 1.3 years. The mean preoperative maximum and mean gradients were 54.2 ± 14.8 mm Hg and 31.6 ± 9.9 mm Hg, respectively. Nine patients underwent transfemoral and one patient underwent transaortic TAV-in-TAV. Mean procedural time was 86.2 ± 51.5 minutes. Post-implantation, the maximum and mean gradients decreased to 18 ± 6.9 mm Hg and 8.4 ± 3.2 mm Hg (16 ± 8 mm Hg and 6.4 ± 1.7 mm Hg in the Evolut-in-Sapien subgroup), respectively. The valve area increased from 0.98 ± 0.28 mm Hg to 1.72 ± 0.32 mm Hg (0.8 ± 0.07 mm Hg to 1.9 ± 0.16 mm Hg in the Evolut-in-Sapien subgroup). Two patients experienced a vascular complication. No further Valve Academic Research Consortium-2 criteria complications occurred during hospitalization.

CONCLUSION

 TAV-in-TAV resulted in low procedural and peri-procedural complication rates. In particular, the usage of a supra-annular valve resulted in excellent hemodynamic results. Larger studies are required to validate this observational data and to establish a protocol for this procedure.

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies

OBJECTIVE

There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons.

METHODS

Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year.

RESULTS

Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I² = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I² = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios.

CONCLUSIONS

In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.

Endovascular snare technique to facilitate delivery of self-expanding valve during transcatheter aortic valve-in-valve replacement in angulated aortas: A case series

BACKGROUND

Transcatheter aortic valve-in-valve replacement (ViV) has been widely accepted as a less invasive alternative to treat failed aortic surgical or transcatheter bioprosthetic valves. Angulated aortas present an additional challenge, particularly when using self-expanding transcatheter heart valves (SE-THV).

METHODS

Two patients with failed surgical bioprosthetic aortic valves and one patient with a failed transcatheter bioprosthetic aortic valve underwent transcatheter aortic ViV using SE-THV. All were deemed high-risk for surgical aortic valve replacement by a heart team. All three patients had initial failed SE-THV delivery using a conventional approach with subsequent successful delivery using the endovascular snare technique.

RESULTS

In Cases 1 and 2, the SE-THV was biased towards the greater curve of the angulated aorta and behind the outer frame of the bioprosthetic valve frame. An endovascular snare was deployed through a secondary left femoral artery access, and the valve delivery system was advanced through the snare in the ascending aorta. The snare was tightened around the SE-THV capsule proximal to the hat-marker, allowing deflection of the SE-THV and successful delivery. In Case 3, the SE-THV interacted with the tall frame of a failed SE-THV. A snare via the left femoral artery was deployed in the descending artery. The SE-THV was advanced through the snare, and both the snare and SE-THV were advanced together to the ascending aorta where the SE-THV was deflected and successfully delivered.

CONCLUSIONS

The endovascular snare technique is a feasible option for successful delivery of SE-THV during transcatheter aortic ViV in failed transcatheter or surgical bioprosthetic valves in angulated aortas.

Safety and efficacy of repeat transcatheter aortic valve replacement for the treatment of transcatheter prosthesis dysfunction

Introduction: Transcatheter aortic valve replacement (TAVR) has recently expanded toward the treatment of younger patients with lower surgical risk and longer life expectancy. Thus, transcatheter heart valve (THV) durability has become a central issue, and an important increase in the number of TAVR-in-TAVR is expected in the coming years. Areas covered: Overview of the current status of TAVR-in-TAVR for the treatment of THV dysfunction, focusing on safety and efficacy of repeat TAVR procedures. Expert opinion: An accurate analysis of the pre-procedure cardiac computed tomography, incorporating new parameters such as the position of the top of the first THV in relation to the sinotubular-junction, will be necessary to assess the risk of coronary occlusion. Subsequent coronary angiography will be necessary in a proportion of TAVR-in-TAVR patients, but coronary access may be very difficult or even impossible in some of them. Therefore, the choice between TAVR and SAVR in young low-risk patients should incorporate the potential need for treating coronary events at mid- to long-term follow-up. Likewise, the choice of the valve type and the implantation position at the time of the first TAVR procedure should take into account the possibility of TAVR-in-TAVR in the future.Abbreviations ACS: acute coronary syndrome; CO: coronary obstruction; EOA: effective orifice area; SAVR: surgical aortic valve replacement; SVD: structural valve degenerationTAVR: transcatheter aortic valve replacement; THV: transcatheter heart valve.

Risk of Coronary Obstruction and Feasibility of Coronary Access After Repeat Transcatheter Aortic Valve Replacement With the Self-Expanding Evolut Valve: A Computed Tomography Simulation Study

BACKGROUND

The supra-annular leaflet position and tall stent frame of the self-expanding Evolut PRO or Evolut PRO+ transcatheter heart valves (THVs) may cause coronary occlusion during transcatheter aortic valve replacement (TAVR)-in-TAVR and present challenges for future coronary access. We sought to evaluate the risk of TAVR-in-TAVR with Evolut PRO or Evolut PRO+ THVs and the feasibility of future coronary access.

METHODS

The CoreValve Evolut PRO Prospective Registry (EPROMPT; NCT03423459) prospectively enrolled patients with symptomatic severe aortic stenosis to undergo TAVR using a commercially available latest generation self-expanding THV at 2 centers in the United States. Computed tomography was performed 30 days after TAVR, which we used to simulate TAVR-in-TAVR with a second Evolut PRO or Evolut PRO+ THV and evaluate for risk of coronary obstruction and feasibility of future coronary access.

RESULTS

Eighty-one patients enrolled with interpretable computed tomography are reported herein. Computed tomography simulation predicted sinus of Valsalva sequestration and resultant coronary obstruction during future TAVR-in-TAVR in up to 23% of patients. Computed tomography simulation predicted that the position of the pinned THV leaflets would hinder future coronary access in up to 78% of patients after TAVR-in-TAVR.

CONCLUSIONS

Further THV design improvements and leaflet modification strategies are needed to mitigate the risk of coronary obstruction during TAVR-in-TAVR with self-expanding THVs and to facilitate future coronary access. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03423459.

Expansion of TAVR into Low-Risk Patients and Who to Consider for SAVR

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis (AS) over the last decade. The results of the Placement of Aortic Transcatheter Valves (PARTNER) 3 and Evolut Low Risk trials demonstrated the safety and efficacy of TAVR in low-surgical-risk patients and led to the approval of TAVR for use across the risk spectrum. Heart teams around the world will now be faced with evaluating a deluge of younger, healthier patients with severe AS. Prior to the PARTNER 3 and Evolut Low Risk studies, this heterogenous patient population would have undergone surgical aortic valve replacement (SAVR). It is unlikely that TAVR will completely supplant SAVR for the treatment of severe AS in patients with a low surgical risk, as SAVR has excellent short- and long-term outcomes and years of durability data. In this review, we outline the critical role that SAVR will continue to play in the treatment of severe AS in the post-PARTNER 3/Evolut Low Risk era.

Redo aortic valve intervention after transcatheter aortic valve replacement: Analysis of the nationwide readmission database

BACKGROUND

Outcomes of redo aortic valve intervention (AVI) following transcatheter aortic valve replacement (TAVR) have not been well described. We thought to investigate the incidence, predictors, and outcomes of redo AVI after TAVR.

METHODS

The Nationwide Readmission Database (from 2012 to 2017) was queried to identify admissions for TAVR. Redo AVI was defined as readmissions that required either TAVR or balloon aortic valvuloplasty (BAV) or surgical aortic valve replacement (SAVR). A multivariable regression model was used to identify independent predictors of redo AVI. In-hospital outcomes of redo TAVR or BAV and redo SAVR were compared in the unadjusted model.

RESULTS

A total of weighted 148,200 (unweighted redo AVI 297, no redo AVI 73,804) index TAVRs were identified. A weighted 593 (435 TAVR or BAV and 158 SAVR) redo AVI was included with an incidence of 1.0 per 100 person-year during a median of 105 (interquartile range 41-195) days follow-up. Predictors of redo AVI were female, heart failure, obesity, atrial fibrillation, transapical approach, oral anticoagulant use, and acute kidney injury. In-hospital mortality of redo AVI was 7.6% (5.3% for redo TAVR or BAV vs. 13.8% for redo SAVR, unadjusted p = 0.10). Stroke, myocardial infarction, bleeding requiring transfusion, new pacemaker, and acute kidney injury rates were 4.7%, 2.6%, 9.3%, 10.0%, and 31.2%, respectively in redo AVI. Length of stay and hospital cost was 4.8 days and 55,826 U.S. dollars, respectively.

CONCLUSIONS

The incidence of redo AVI was low following TAVR but was associated with high mortality and morbidities.