In a groundbreaking study, researchers delved into the intricate realm of aortic valve interventions, shedding light on the comparative outcomes of two distinct approaches: valve-in-valve transcatheter aortic valve replacement and redo surgical aortic valve replacement. This retrospective population-based cohort analysis, spanning from 2015 to 2020, involved 1,771 patients who had previously undergone bioprosthetic SAVR and subsequently required intervention for valve failure.
The study's design was meticulous, with propensity matching yielding 375 patient pairs to ensure a balanced comparison between the two treatment modalities. The primary outcome measure was all-cause mortality, while secondary outcomes included stroke, heart failure hospitalization, reoperation, major bleeding, acute kidney failure, new pacemaker insertion, and infective endocarditis.
The findings revealed a striking trend: the proportion of patients undergoing ViV-TAVR versus redo SAVR increased significantly during the study period, rising from 35.3% in 2015 to 62.5% in 2020. This surge in ViV-TAVR adoption underscores the growing acceptance and accessibility of this minimally invasive approach.
Periprocedural mortality and stroke rates were similar between the propensity-matched groups, indicating comparable safety profiles for both interventions. However, the ViV-TAVR group demonstrated lower periprocedural rates of major bleeding (2.4% vs. 5.1%), acute kidney failure (1.3% vs. 7.2%), and new pacemaker implantations (3.5% vs. 10.9%), highlighting potential advantages in terms of reduced complications.
Interestingly, the 5-year all-cause mortality rate was higher in the ViV-TAVR group (23.4%) compared to the redo SAVR group (13.3%). A landmark analysis revealed no difference in mortality up to 2 years post-procedure, but beyond that point, ViV-TAVR was associated with a higher mortality risk (hazard ratio of 2.97) and a higher incidence of heart failure hospitalization (hazard ratio of 3.81).
The study's authors acknowledged the potential influence of residual confounding factors and emphasized the need for further investigation through a randomized clinical trial. Despite the observed differences in long-term outcomes, the incidence of stroke, reoperation, major bleeding, and infective endocarditis was similar between the two groups over the 5-year follow-up period.
This comprehensive analysis not only sheds light on the comparative efficacy and safety profiles of ViV-TAVR and redo SAVR but also underscores the importance of individualized patient assessment and shared decision-making. As the field of aortic valve interventions continues to evolve, such studies pave the way for refining treatment strategies and optimizing outcomes for patients with failed bioprosthetic aortic valves.
