The evidence supporting transcatheter aortic valve replacement (TAVR) has expanded dramatically over the past decade, starting from being recommended in patients with severe symptomatic aortic stenosis (AS) at high risk for surgical complications to most recently expanding to include asymptomatic patients with severe AS. As a result, utilization of TAVR has increased dramatically, with the largest increase seen in patients under the age of 65 years, followed by the age group 65 to 80 years. , As a younger TAVR cohort lives longer postprocedure, the question of structural valve deterioration becomes relevant for a much larger percentage of patients than ever before. While data on valve durability for both TAV and surgical aortic valves (SAV) are highly variable, many reports ,, agree that structural valve deterioration occurs in about 10% of patients at 10 years after implantation of a bioprosthetic valve. Many of these patients need a valve-in-valve TAVR, which is a procedure of increased complexity, performed in what is often a more elderly and frail population. As a result, the possibility of reintervention further down the road should be taken into account while planning the index valve procedure.
A prior study has demonstrated that procedural success is more slightly likely in TAV-in-TAV compared to TAV-in-SAV (72.7% vs 62.4%, p = 0.045). In addition, outcomes measured up to 1 year after the procedure were similar between the groups, with similar numbers for procedural safety endpoints, 30-day mortality, and 1-year mortality. No prior data exists for outcomes beyond 1 year.
In a recent issue of the American Journal of Cardiology, Rosenzveig et al present a brief report investigating the outcomes of TAV-in-TAV and TAV-in-SAV up to 3 years after the procedure. The authors interrogate the TriNetX database to identify patients who underwent valve-in-valve TAVR and had recorded follow-up to 3 years. A cohort of 398 patients with valve-in-valve TAVR were initially identified. Patients with TAV-in-TAV were older (74.2 ± 8.5 vs 69.7 ± 10.6 years, p < 0.01), more frequently had chronic kidney disease (58% vs 38%), and chronic lower respiratory disease (59% vs 42%) compared to TAV-in-SAV. Propensity score matching was applied using 27 covariates, with the resulting cohorts being matched 1:1 with no significant residual differences, and 85 patients in each cohort. After matching, mortality (29% vs 20%, p = 0.24), major adverse cardiovascular events (31% vs 27%, p = 0.68), major adverse kidney events (13% vs 12%, p = 0.24), and endocarditis (13% vs 22%, p = 0.06) were similar in TAV-in-TAV vs TAV-in-SAV groups.
This article expands the comparative data for TAV-in-TAV and TAV-in-SAV cohorts with outcomes to 3 years. Minimal differences between were noted between the two groups. This makes valve-in-valve TAVR a viable option, regardless of surgical versus transcatheter implantation. However, the data presented here has limitations. The authors appropriately point out the use of a large deidentified patient database as a potential weakness. The strength of the TriNetX database lies in more than 100 million electronic health records and more than 14,000 logged TAVRs. However, the database is not geared toward TAVR, or cardiac disease specifically, and thus does not capture many variables that are better captured in a dedicated database such as the TVT registry. Data collected is limited largely to ICD-10 codes and procedural codes. Further, there are fundamental clinical and physiological differences between patients that underwent open-heart aortic valve surgery and patients who underwent a minimally invasive valve replacement procedure. Nullifying these differences using propensity score matching likely obscures many clinical nuances, which in turn may have affected the outcomes. In addition, the small number of patients that were ultimately included limits observable effect sizes, and may also be hiding small differences between the groups.
Despite these drawbacks, this article does an excellent job of reporting on comparative outcomes of TAV-in-TAV and TAV-in-SAV, especially at 3 years of follow-up. This provides good preliminary data that valve-in-valve TAVR is feasible for both transcatheter and bioprosthetic SAV. This, in turn, supports the hypothesis that early TAVR, including in asymptomatic patients with severe AS, can be followed up with valve-in-valve TAVR further down the road.
CRediT authorship contribution statement
Kinjal Banerjee: Conceptualization, Writing– original draft, Writing– review & editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.
Abbreviations: TAVR, transcatheter aortic valve replacement; AS, aortic stenosis; TAV, transcatheter aortic valve; SAV, surgical aortic valve.
Ethics Statement: This article is an invited editorial, and as a result, no ethical approval was obtained.
Funding: No funding was utilized for the preparation of this article.
References
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