Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w
­­Valve-in-valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement for failed surgical aortic bioprostheses: A systematic review and meta-analysis
S. de Waha1, M. Raschpichler1, D. Holzhey2, G. Schwarzer3, N. Flint4, D. Kaewkes4, P. T. Bräuchle1, D. Dvir5, R. Makkar4, G. Ailawadi6, M. Abdel-Wahab7, H. Thiele7, M. A. Borger1
1Universitätsklinik für Herzchirurgie, Herzzentrum Leipzig - Universität Leipzig, Leipzig; 2Klinik für Herz- und Thoraxchirurgie, Helios Klinikum Wuppertal - Herzzentrum, Wuppertal; 3Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Freiburg, Freiburg; 4Cedars-Sinai Medical Center, Los Angeles, US; 5Shaare Zedek Medical Center, Hebrew University, Jerusalem, IL; 6Cardiovascular Center, Michigan Medicine University of Michigan, Ann Arbor, US; 7Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universität Leipzig, Leipzig;

BACKGROUND: In the absence of randomized controlled trials, reports from non-randomized studies comparing valve-in-valve implantation (ViV) to redo surgical aortic valve replacement (rAVR) have shown inconsistent results.

METHODS AND RESULTS: PubMed/MEDLINE, Google Scholar, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched through December 2021. MOOSE guidelines were followed. The protocol was registered at PROSPERO. Random effects models were applied. The primary outcomes of interest were short- and mid-term mortality. Secondary outcomes included stroke, myocardial infarction, acute renal failure, and permanent pacemaker implantation, as well as prosthetic aortic valve regurgitation, mean transvalvular gradient, and severe prosthesis-patient mismatch.

Of 8,881 patients included in 15 studies, 4,458 (50.2%) underwent ViV and 4,423 (49.8%) rAVR. Short-term mortality was 2.8% in patients undergoing ViV compared to 5.0% in rAVR patients (risk ratio [RR] 0.55, 95% confidence interval [95%CI] 0.34-0.91, p=0.02). Mid-term mortality did not differ in patients undergoing ViV compared to patients undergoing rAVR (hazard ratio 1.27, 95%CI 0.72-2.25). The rate of acute kidney failure was lower following ViV (RR 0.54, 95%CI 0.33-0.88, p=0.02), whereas prosthetic aortic valve regurgitation (RR 4.18, 95%CI 1.88-9.3, p=0.003) as well as severe patient-prothesis mismatch (RR 3.12, 95%CI 2.35-4.1, p<0.001) occurred more frequently. The mean transvalvular gradient was higher following ViV (standard mean difference 0.44, 95%CI 0.15-0.72, p=0.008). There were no significant differences between groups with respect to stroke (p=0.26), myocardial infarction (p=0.93), or pacemaker implantation (p=0.21).

CONCLUSION: Results of this meta-analysis demonstrate better short-term mortality after ViV compared to rAVR. Mid-term mortality was similar between groups. Given the likely selection bias in these individual reports, an adequately powered multicenter randomized clinical trial with sufficiently long follow-up in patients with low-to-intermediate surgical risk is warranted.

https://dgk.org/kongress_programme/jt2023/aV1498.html