Valve-in-Valve Transcatheter Aortic Valve Replacement in Intermediate-risk Patients

Clinical and hemodynamic outcomes of self-expanding and balloon-expandable valves for valve-in-valve transcatheter aortic valve implantation (ViV-TAVI): An updated systematic review and meta-analysis

Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has emerged as a feasible alternative to reoperative surgery in patients with degenerated surgical bio-prosthesis. However, data regarding the choice of valve type in ViV-TAVI remain inconclusive. This meta-analysis compares the procedural and clinical outcomes of self-expanding (SE) vs. balloon-expandable (BE) valves in ViV-TAVI. MEDLINE and Scopus were queried to identify studies reporting outcomes of ViV-TAVI by SE/BE valve type or comparing outcomes between SE or BE valves for ViV-TAVI. The primary outcome was incidence of all-cause mortality at 30 days. Data were presented as incidence of outcomes, analyzed via random effects model using inverse variance method with 95 % confidence intervals. Further incidence rates of primary and secondary outcomes were presented as subgroups of BE and SE, with comparison in incidence rates between the subgroups made using p-interaction of proportions. 27 studies with 13,182 patients (SE: 7346; BE: 5836) were included. There were no significant differences between the BE vs. SE valves in 30-day mortality (BE 4 % vs. SE 3 %, p = 0.44), 1-year mortality (BE 12 % vs. SE 10 %, p = 0.60), and moderate-to-severe AR at 1 year (BE 1 % vs. SE 3 %, p = 0.36). However, patients with SE valves had higher rates of new permanent pacemaker insertion (BE 4 % vs. SE 9 %, p = 0.0019). There were no significant differences in the incidence of 30-day safety outcomes, including stroke, AKI, coronary obstruction, major bleeding, and major vascular complications. Both BE and SE valve types showed comparable mortality and safety outcomes in ViV-TAVI, except pacemaker insertion, which was higher in SE compared with BE valves.

Meta-analysis Comparing Valve-In-Valve Transcatheter Aortic Valve Implantation With Self-Expanding Versus Balloon-Expandable Valves

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is an alternative to redo-surgery in patients with failed surgical bioprostheses. It remains unclear whether outcomes vary when using either self-expanding (SE) or balloon-expandable (BE) valves. The aim of this study was to compare outcomes between SE and BE transcatheter heart valves when used for ViV TAVI. A systematic review of PubMed, MEDLINE, and EMBASE was performed identifying studies reporting outcomes following ViV TAVI. Event rates were pooled for meta-analysis using a random-effects model. The primary outcome was all-cause mortality at 12 months. Secondary outcomes included 30-day and 3-year mortality in addition to standard safety outcomes after the procedure as per the Valve Academic Research Consortium criteria. Nineteen studies reporting outcomes for 1,772 patients were included: 924 in the SE group and 848 patients in the BE group. There was no significant difference in all-cause mortality at 12 months (SE 10.3% vs BE 12.6%, p = 0.165, I² = 0%), or 3 years (SE 21.2% vs BE 31.2%, p = 0.407, I² = 63.79). SE valves had lower transvalvular gradients after procedure and acute kidney injury, but higher rates of pacemaker insertion, moderate or severe paravalvular regurgitation and need for ≥2 valves (all p < 0.05). There were no differences in stroke, coronary obstruction, bleeding, or vascular complications. Despite significant differences in key procedural outcomes between SE and BE valves when used for ViV TAVI, we found no difference in 12-month mortality. Tailored device selection may further reduce the risk of adverse procedural outcomes, particularly over the longer term.