title: What is the best approach in a patient with a failed aortic bioprosthetic valve: transcatheter aortic valve replacement or redo aortic valve replacement?
abstract: A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether transcatheter aortic valve-in-valve replacement (viv-TAVR) or redo aortic valve replacement (rAVR) is the best strategy in a patient with a degenerative bioprosthetic aortic valve. Altogether, 162 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The results of the studies provided interesting results. All the studies are retrospective. Four papers reported the results of redo aortic valve replacement in patients with failed aortic bioprosthetic valve, six papers demonstrated their results with transcatheter aortic valve-in-valve replacement for the same indication and two papers reported their propensity-matched analysis of outcomes between viv-TAVR and rAVR in patients with previous cardiac surgery. Thirty-day mortality for rAVR was 2.3-15.5% and 0-17% for viv-TAVR. For rAVR, survival rate at 30 days was 83.6%, 76.1% at 1 year, 70.8% at 3 years, at 51.3-66% at 5 years, 61% at 8 years and 61.5% at 10 years. For viv-TAVR, the overall Kaplan-Meier survival rate at 1 year was 83.2%. After viv-TAVR at 1 year, 86.2% of surviving patients were at New York Heart Association (NYHA) class I/II. The complications after rAVR were stroke (4.6-5.8%), reoperation for bleeding (6.9-9.7%), low-cardiac output syndrome (9.9%) whereas complications after viv-TAVR at 30 days were major stroke (1.7%), aortic regurgitation of at least moderate degree (25%), new permanent pacemaker implantation rate (0-11%), ostial coronary obstruction (2%), need for implantation of a second device (5.7%) and major vascular complications (9.2%). It is noteworthy to mention that there is a valve-in-valve application that provides information to surgeons for choosing the correct size of the TAVR valve. Transcatheter aortic valve-in-valve procedures are clinically effective, at least in the short term, and could be an acceptable approach in selected high-risk patients with degenerative bioprosthetic valves. Redo AVR achieves acceptable medium and long-term results. Both techniques could be seen as complementary approaches for high-risk patients.
authors.affiliation: University of Ioannina Medical School, Ioannina, Greece christostourmousoglou@hotmail.com.
authors.forename: Christos
authors.initials: C
authors.lastname: Tourmousoglou
authors.affiliation: Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, University of Toronto, Toronto, Canada.
authors.forename: Vivek
authors.initials: V
authors.lastname: Rao
authors.affiliation: Department of Cardiothoracic Surgery, Hippokratio General Hospital, Athens, Greece.
authors.forename: Spiros
authors.initials: S
authors.lastname: Lalos
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Patra, Patra, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Dougenis
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D019985:Benchmarking; D001705:Bioprosthesis; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D020878:Device Removal; D019317:Evidence-Based Medicine; D005260:Female; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic valve; Bioprosthesis; Failed; Implantation