Surprising Tradeoffs of Valve-in-Valve TAVR vs Redo Surgery

Compared with redo surgery for a failed aortic bioprosthesis, valve-in-valve transcatheter aortic valve replacement (TAVR) offered some clinical advantages in the hospital at the expense of higher readmissions later on, researchers found.

The incidence of in-hospital mortality favored patients getting valve-in-valve TAVR instead of surgical aortic valve replacement (SAVR) after propensity matching between groups (1.2% vs 3.4%; OR 0.39, 95% CI 0.19-0.80), according to records from 2016 to 2018 in the Nationwide Readmission Database.

However, a major weakness of valve-in-valve TAVR appeared to be all-cause readmissions, both at 30 days (16.1% vs 11.5%; HR 1.42, 95% CI 1.09-1.86) and at 6 months (33.8% vs 24.5%; HR 1.42, 95% CI 1.05-1.92), reported Ankur Kalra, MD, of Cleveland Clinic, at TVT: The Structural Heart Summit, an annual meeting held by the Cardiovascular Research Foundation and hosted this year in Miami Beach.

The top reasons for readmission in the TAVR group were heart failure, blood transfusion, and sepsis.

Unexpectedly, valve-in-valve TAVR was associated with an uptick in pneumonia and other non-cardiac infections, a finding highlighted by TVT session moderator Gorav Ailawadi, MD, of University of Michigan Health in Ann Arbor.

Another “surprising” finding from the observational study was the lack of difference in pacemaker implants between valve-in-valve TAVR and SAVR (12.9% vs 8.2%, P=0.117), Kalra noted.

He reported other in-hospital morbidity and procedural complication rates for the two cohorts:

• Acute stroke: 9.7% for both (P=0.423)

• Acute kidney injury: 18.1% vs 24.6% (P=0.015)

• Major bleeding: 29.7% vs 67.7% (P<0.001)

• Cardiorespiratory complications: 9.3% vs 26.5% (P=0.002)

• Valvular complications: 1.8% vs 2.1% (P=0.52)

Study results represent contemporary data since FDA approved valve-in-valve TAVR in 2015.

From the Nationwide Readmission Database, Kalra’s group had identified more than 10,000 individuals who underwent a second valve procedure after TAVR or SAVR.

After exclusions (e.g., discharge in the month of December, concurrent valve surgery, concurrent coronary artery bypass grafting surgery), the investigators were left with people who received valve-in-valve TAVR (n=3,724) or repeat SAVR (n=3,045) for the present analysis.

People undergoing valve-in-valve TAVR were more likely to be women and older compared with repeat SAVR recipients. This was also a sicker cohort with more comorbidities at baseline.

The share of valve-in-valve TAVR, among interventions for a failed aortic bioprosthesis, ticked upward from approximately 50% in the first quarter of 2016 to about 60% in the fourth quarter of 2018, according to Kalra.

He cautioned that the administrative database used for the study lacked important clinical and procedural variables, as well as prior valve characteristics and echocardiographic data. As such, his group was unable to calculate STS-PROM or EuroSCORE risk scores for each patient.

A manuscript of the study is under peer review at a journal, Kalra noted.