Redo Surgical Aortic Valve Replacement versus Valve-in-Valve Transcatheter Aortic Valve Replacement for Degenerated Bioprosthetic Valves.

Background: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is associated with improved perioperative safety compared to redo surgical aortic valve replacement (redo-SAVR), but long-term outcomes remain uncertain. We therefore compare long-term outcomes of ViV-TAVR and redo-SAVR.

Methods: The study included 1:1 propensity-matched Medicare beneficiaries with degenerated bioprosthetic valves admitted between 09/29/2011 and 12/30/2020 undergoing either redo-SAVR or ViV-TAVR. Exclusion criteria included endocarditis, other concomitant cardiac surgery, or aortic valve re-intervention during the same admission. The primary outcome was 5-year survival. Composite secondary outcomes included major adverse cardiovascular events (MACE; 30-day operative mortality, stroke, or acute myocardial infarction) and major valve event-free survival (congestive heart failure readmission, endocarditis, or aortic valve reintervention). Time-to-event analyses utilized Kaplan-Meier analysis and multivariable Cox proportional hazard modeling.

Results: Overall, 4,699 patients were identified including 1,775 redo-SAVR and 2,924 ViV-TAVR patients. Redo-SAVR patients were younger (median[IQR] 72[68,77] vs 79[73,84]) with less CHF(39.6% vs. 68.8%) and prior CABG (17.9% vs. 32.0%) (all p<0.05). In the propensity-matched cohorts of 1,256 patients each, redo-SAVR had higher MACE (17.4% vs 13.2%, p=0.003), but better major valve event-free (71[62,79] vs 43[38,47] months, p<0.001) and 5-year (62.3% vs 46.7%, p<0.001) survival. After stratification by Charlson Comorbidity Index, the long-term survival benefit persisted in patients of lower (67.6% vs 54.9%, p=0.001) and medium or higher-risk (55.1% vs 36.7%, p<0.001).

Conclusions: Redo-SAVR may have better long-term survival than ViV-TAVR despite greater perioperative morbidity. Clinical trial data is needed to fully inform clinical decision-making regarding degenerated bioprosthetic valve reintervention, particularly for patients with reasonable life expectancy.