title: Reoperative Surgical Aortic Valve Replacement Versus Transcatheter Valve-in-Valve Replacement for Degenerated Bioprosthetic Aortic Valves.
abstract: BACKGROUND
  Bioprosthetic aortic valve use has increased steadily according to The Society of Thoracic Surgeons (STS) database analyses. One of the momentums toward this trend is the future utilization of transcatheter valve-in-valve (TViV) techniques when bioprosthetic valves fail. We compared the results of reoperative TViV to surgical aortic valve replacement (SAVR) for degenerated bioprosthetic valves.
  
  
  METHODS
  From January 2002 to January 2015, we identified 91 patients with degenerated bioprosthetic valves who underwent isolated AVR (SAVR n = 69, TViV n = 22). Patients with prior homografts or active endocarditis were excluded. The STS risk score was used to create 22 matched pairs of SAVR and TViV for comparison.
  
  
  RESULTS
  Before matching, mean STS risk scores were 4.36 ± 3.1 and 7.54 ± 3.0 for SAVR and TViV, respectively (p = 0.001), but were 7.70 ± 3.4 and 7.54 ± 3.0, respectively (p = 0.360), after matching. Mean age was 74.5 ± 10.4 years for SAVR and 75.0 ± 9.6 years for TViV (p = 0.749). Operative mortality was 4.3% (1 of 22) in the SAVR group and zero for TViV (p = 1.00). Mean postoperative gradient was 13.5 ± 13.2 mm Hg for SAVR and 12.4 ± 6.2 mm Hg for TViV (p = 0.584). There was no coronary obstruction in either group, but 22% of TViV (5 of 22) had mild paravalvular leaks versus none in the SAVR group (p = 0.048). Postoperative stroke rate was 9% (2 of 22) for SAVR and zero for TViV (p = 0.488). The TViV group had shorter median length of stay (5 versus 11 days, p = 0.001). Actuarial survival at 3 years was 76.3% (95% confidence interval: 58.1 to 94.5) versus 78.7 (95% confidence interval: 56.2 to 100) for SAVR and TViV, respectively (p = 0.410).
  
  
  CONCLUSIONS
  For degenerated bioprosthetic aortic valves, TViV has similar operative mortality, strokes rates, and survival as SAVR in this high-risk cohort. Therefore, TViV is a viable alternative to SAVR, although studies using registry data are needed to establish noninferiority.
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Julius I
authors.initials: JI
authors.lastname: Ejiofor
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Maroun
authors.initials: M
authors.lastname: Yammine
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Morgan T
authors.initials: MT
authors.lastname: Harloff
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Siobhan
authors.initials: S
authors.lastname: McGurk
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Jochen D
authors.initials: JD
authors.lastname: Muehlschlegel
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Prem S
authors.initials: PS
authors.lastname: Shekar
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Cohn
authors.affiliation: Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Pinak
authors.initials: P
authors.lastname: Shah
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: tkaneko2@partners.org.
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Kaneko
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000601:surgery*; D001705:Bioprosthesis / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D011475:Prosthesis Failure; D012042:Registries; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*