Valve-in-valve transcatheter aortic valve replacement versus redo aortic valve replacement: which procedure for which patient?

ABSTRACT

Introduction

Bioprosthetic aortic valves are increasingly being utilized in a younger population due to improved durability and possibility for future valve-in-valve replacement. This has resulted in a larger population of patients with bioprosthetic aortic valve degeneration requiring re-intervention. Despite no head-to-head comparisons between redo surgical aortic valve replacement (SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR), observational studies suggest a comparable long-term risk between which led to the incorporation of ViV TAVR to current guidelines.

Areas covered

This article summarizes the comparative performance of redo SAVR versus ViV TAVR in patients with bioprosthetic valve dysfunction and provides a guide to better understand which procedure is best for which patient.

Expert opinion

With the rising use of TAVR, we will be confronted with more bioprosthetic aortic valve degeneration requiring re-intervention. Based on the available evidence and expert consensus, we propose that patients with bioprosthetic aortic valve degeneration be treated with ViV TAVR if they have a history of radiation heart disease, prohibitive surgical risk, and multiple sternotomies; while patients with small prostheses, history of infective endocarditis, those at high risk for coronary obstruction, and those with need for other cardiac surgery will be managed with redo SAVR.

KEYWORDS:

• Redo SAVR
• ViV TAVR
• bioprosthetic aortic stenosis
• transcatheter therapies
• cardiac surgery
• outcomes

Article highlights

• ViV TAVR is recommended for patients with bioprosthetic valve degeneration who are deemed to have a high or prohibitive risk for SAVR.

• There is growing evidence suggesting that ViV TAVR is feasible and safe in lower risk populations and short-term outcomes are comparable to native TAVR.

• Despite no head-to-head comparisons between redo SAVR and ViV TAVR, observational studies show comparable short-term outcomes and, possibly better, long-term outcomes after ViV TAVR.

• The decision to proceed with redo SAVR vs ViV TAVR should be based on patient and valve characteristics, shared decision-making and a multidisciplinary team approach in a center with high-level expertise.

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.