Repeat TAVR an ‘important’ option for aortic-valve re-intervention

Reuters Health - 05/08/2021  - Repeat transcatheter aortic-valve replacement (TAVR) can be performed with "acceptable" 30-day mortality, with short-term outcomes that are better than surgical explantation, according to real-world data.

"Given the favorable short-term outcome, repeat TAVR will be an important option for aortic valve reintervention in the lifetime management of aortic valve disease in appropriately selected patients," researchers write in JACC: Cardiovascular Interventions.

For valvular re-intervention after TAVR, surgical explantation of the TAVR prosthesis (TAVR explantation) and repeat TAVR are the two possible options.

Dr. Edward Percy of Brigham and Women's Hospital - Harvard Medical School in Boston and colleagues evaluated all 133,250 Medicare patients who underwent primary TAVR from 2012 to 2017, including 617 (0.46%) who underwent repeat TAVR at a median of 154 days after first TAVR. Patients in the repeat-TAVR group were 81 years old on average and 42% were women; comorbidities were common.

The 30-day and one-year mortality rates with repeat TAVR were 6.0% and 22%, respectively. Both 30-day and one-year mortality following repeat TAVR were significantly lower in patients who underwent primary TAVR between 2015 and 2017 than between 2012 and 2014.

Rates of 30-day stroke and pacemaker insertion with repeat TAVR were 1.8% and 4.2%, respectively.

The researchers also did a matched analysis comparing 257 repeat TAVR patients with 130 surgical TAVR explantation patients over the same time period. In this analysis repeat TAVR was associated with lower 30-day mortality (6.2% vs. 12.3%; P=0.05) with no difference in one-year mortality (21.0% vs. 20.8%; P=1.00).

Compared with surgical TAVR explantation, repeat TAVR was associated with fewer bleeding complications, shorter length of stay and a lower incidence of major cardiac events at 30 days.

"As TAVR is increasingly applied in younger individuals, providers and patients should consider the risks and benefits of these repeat interventions at the time of initial valve replacement," Dr. Percy and colleagues say.

Their findings, they say, "provide the first step to the necessary information in this shared decision-making process, as repeat TAVR becomes an increasingly relevant tool in the lifetime management of aortic valve disease."

In an editorial comment, Dr. Giuseppe Tarantini and Dr. Nai Fovino of Padova University Hospital, in Italy, advise that when approaching a patient with aortic stenosis whose life expectancy exceeds the anticipated life of the valve prosthesis, "the heart team should envisage the impact of the first intervention on future therapeutic options."

"Although there is likely not one strategy for everybody, a patient- tailored approach should be pursued, based on the predicted relation between the bioprosthesis and the aortic root structures at the time of index procedure," they write.

"TAVR-in-TAVR will represent a less invasive, valuable therapeutic option in the lifetime strategy of patients with aortic stenosis, but it will not be possible for every patient. We must be aware that the first therapeutic decision is the game changer for the long-term future of our patients with aortic stenosis. The first cut will be the deepest," the editorialists say.

The study did not have commercial funding. Several authors report ties to device makers.

SOURCE https://bit.ly/3jgy9ud and https://bit.ly/3Ach7nX JACC: Cardiovascular Interventions, online August 2, 2021.

By Reuters Staff



Posted on 5 August, 202117 August, 2021