Aortic Valve-in-Valve Procedures in Bioprostheses vs. Transcatheter Heart Valves

Background: Aortic Valve-in-Valve (ViV) procedures for degenerated bioprosthetic surgical aortic valve replacement (SAVR) is an established therapy. Due to rising numbers of transcatheter aortic valve implantation (TAVI), an increase in failure of transcatheter heart valves (THV) is observed. Whether ViV for failing THV presents similar efficacy compared with ViV for SAVR is unclear. We herein compared ViV for SAVR versus THV.

Methods: Between 2008 and 2024, 352 ViV procedures were performed at our center. Baseline, periprocedural, and outcome parameters were retrospectively analyzed.

Results: ViV was performed for SAVR in 315/352 patients (89.5%) (group 1) and in 37/352 patients (10.5%) for THV (group 2) (age: SAVR 77.2 ± 8.1 versus THV 78.9 ± 7.7 years, p = 0.199; male: 59.0 versus 54.1%, p = 0.560; STS-PROM: 5.5 ± 5.2 versus 5.4 ± 3.5%, p = 0.925). Degenerated SAVR included Hancock (24.5%), Perimount (22.3%), Mitroflow (21.2%), and Mosaic (7%), degenerated THV included Sapien (57.7%), Evolut (23.1%), and Acurate (15.4%). Time to ViV was significantly longer in SAVR (11.7 ± 4.5 versus 5.3 ± 5.8 years; p < 0.001). Implanted prostheses during ViV consisted of Evolut (50.8%), Sapien (30.3%), Allegra (9.6%), and Navitor (4.0%). Evolut was more frequently used in SAVR (56.8% versus 21.1%, p < 0.001), Sapien more often in THV (26.0% versus 68.4%, p < 0.001). TrueID was lower in SAVR (21.1 ± 2.4 versus 23.2 ± 2.8 mm; p < 0.001) leading to smaller sizes of implanted valves (24.33 ± 1.81 versus 25.53 ± 2.29 mm; p = 0.004). BASILICA (12.6% versus 5.9%, p = 0.198) and cerebral embolic protection (41.3% versus 21.6%, p = 0.042) were performed more frequently in SAVR. Post-ViV mean gradient (14.9 ± 7.6 versus 12.3 ± 7.6 mm Hg, p = 0.053) and rate of PVL ≥ mild (1.0% versus 5.3%; p = 0.09) were similar. 30-day mortality (3.9% versus 0.0%, p = 0.375) was similar as well as rates of stroke (2.8% versus 0%, p = 0.805), PPI (2.8% versus 2.6%, p = 0.853), reintervention (0.6% versus 2.6%, p = 0.206), and rehospitalization (1.9% versus 2.6%, p = 0.139).

Conclusion: While ViV procedures for degenerated SAVR and THV present similar clinical safety and efficacy, procedural measures during ViV differ between groups in terms of utilized valves and valve sizes as well as concomitant procedures such as implementation of cerebral embolic protection systems. Of note, time to ViV was distinctly shorter after TAVI suggesting that a marked increase of ViV for THV must be anticipated.

Publication History

Article published online:
11 February 2025