"Compared with surgery, the less invasive nature of TAVR is undoubtedly a benefit," Dr. Uri Landes told Reuters Health by email. "The tendency to treat younger patients with longer life expectancy with transcatheter approach is likely to continue, as does the trend to treat more and more patients with bioprosthetic (vs. mechanical) valves."
"The downside," he added, "is that a sizable proportion of patients treated with either TAVR or surgery may require reintervention later in their lives. Therefore, we must learn the advantages and disadvantages of each type of reintervention in order to make optimal upstream decisions."
For their study, published in the Journal of the American College of Cardiology, Dr. Landes of Tel Aviv University, in Israel, and colleagues examined data from Redo-TAVR, a registry involving 37 centers from Europe, North America and the Middle East.
Following propensity matching, they compared outcomes in 165 TAV-in-TAV and 165 TAV-in-SAV patients. At 30 days, procedural success was achieved in 72.7% of the TAV-in-TAV group compared to 62.4% of the TAV-in-SAV patients (P<0.05). This difference was driven largely by lower residual aortic-valve gradient in the TAV-in-TAV patients.
Mortality in TAV-in-TAV patients was 3.0% at 30 days versus 4.4% with TAV-in-SAV (P=0.56); at one year, mortality rates were 11.9% and 10.2% (P=0.63), respectively.
Compared with TAV-in-SAV, the residual aortic-valve gradient was lower and the frequency and grade of aortic regurgitation higher in the TAV-in-TAV group.
Dr. Landes said "the lack of a sewing ring and greater expandability of transcatheter devices is likely an advantage for valve-in-valve because patients end up with lower residual aortic-valve gradients. On the other hand, that lack of a relatively rigid ring might also be a cause of ending up with more residual aortic regurgitation as the study implies."
"Of course," he added, "other reasons can also play a role and a lot more study is required to fully understand and optimize the valve-in-valve-in-root interactions."
Dr. Anthony A. Bavry of UT Southwestern Medical Center, in Dallas, Texas, coauthor of an accompanying editorial, told Reuters Health by email, "With the high penetrance of TAVR, we are going to see an increase in the number of TAV-in-TAV procedures."
He said the study "suggests that this practice is safe; however, this is a special population which will require an ongoing appraisal of efficacy and safety."
SOURCE: https://bit.ly/2JNOpVF and https://bit.ly/38ll5zw Journal of the American College of Cardiology, online January 4, 2021.
By David Douglas
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