Valve-in-valve transcatheter aortic valve implantation for degenerative stentless versus stented surgical bioprostheses

Abstract

Abstract Introduction Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is a viable and less-invasive alternative to open heart surgery in selected patients with bioprosthetic valve dysfunction. Most ViV-TAVI procedures have been performed in failing stented bioprosthetic valves; stentless bioprostheses lack fluoroscopic markers and could be more challenging for transcatheter therapy. Data on more recent patients applying Valve Academic Research Consortium (VARC)-3 defined outcomes are scarce; thus, we compared patient characteristics, procedural outcomes, and 1-year outcomes of patients with stentless (SL) versus stented (ST) aortic bioprosthetic device failure undergoing ViV-TAVI. Methods Patients undergoing ViV-TAVI between 2007 and 2022 (53% of cases after 2015) at 3 German centres were included in this analysis. The 1-year mortality was the primary outcome measure, secondary outcomes included VARC-3 defined technical and device success and early safety. Results Overall, 43 (11.8%) SL and 313 (88.2%) ST ViV-TAVI were included. Patients were comparable with regard to age (SL: 77 (74; 82) vs. ST: 78 (75; 83), p=0.08), sex (male: SL 70% vs. ST 56%, p=0.08), clinically relevant baseline comorbidities and surgical risk (STS PROM SL 10.0 (4.8; 12.5) % vs. ST 9.4 (4.5; 11.3) %, p=0.62). Aortic regurgitation was the mode of failure in 33% of SL vs. 8% in ST (p<0.01). The rate of self-expanding TAVI prostheses was 86% and 76% in SL and ST, respectively (p=0.15). The rates of technical success (SL: 84% vs ST: 80%, p=0.55), device success (SL: 67% vs ST: 54%, p=0.11), and early safety (SL: 74% vs ST: 62%, p=0.30) were comparable between groups. There were higher rates of mild/moderate residual aortic regurgitation in SL (77.5% vs. 35%, p<0.01), whereas the remaining mean gradient was higher in ST (11.2 (6.0; 15.5) mmHg vs. 17.0 (11.0; 22.0) mmHg, p<0.01). The 30-day mortality rate (SL: 7.0% vs. ST: 2.6%, p=0.14) and Kaplan-Meier estimated 1-year mortality rates (SL: 9.3% vs. ST: 8.2%, p=0.63) were comparable between groups. Conclusion Both SL and ST ViV-TAVI have comparable short-term outcomes according to VARC-3- defined endpoints and similar low rates of 1-year all-cause mortality. However, against the background of a relevant rate of residual aortic regurgitation in SL and increased gradients in ST, long-term studies are of utmost importance to determine the clinical relevance of those factors.