Repeat TAVR Outcomes 'Reassuring'

Debra L Beck

April 28, 2020

Redo-transcatheter aortic valve replacement (TAVR) is a reasonably safe and effective option for selected patients with valve dysfunction after TAVR, new registry data suggest.

"Redo TAVR is about to become a much more common procedure and it's reassuring to see that the outcomes that can be achieved by these procedures are quite good," said Uri Landes, MD, Vancouver General Hospital, British Columbia, Canada.

Landes and colleagues reported results from the Redo-TAVR Registry in the April 28 issue of the Journal of the American College of Cardiology.

The Redo-TAVR Registry is an investigator-initiated effort designed to collect information on patients who undergo a second TAVR within a dysfunctional transcatheter heart valve (THV).

From 63,876 TAVR procedures done at 37 participating centers, 212 (0.33%) were redo-TAVR procedures. Seventy-four of the redo procedures were done within 1 year of the initial TAVR and the remaining 138 were beyond 1 year. Median time from TAVR-to-redo-TAVR for these two groups was 68 (38 to 154) days and 5 (3 to 6) years, respectively.

"It's important to understand that this is probably a highly selected group of patients and these numbers do no reliably reflect the ratio of patients who will need a redo TAVR," said Landes in an interview with | Medscape Cardiology.

"We don't know how many patients were excluded from redo TAVR because of prohibitive anatomical factors, such as an anticipated high risk for coronary occlusion, or a patient prosthesis mismatch. Also, some of these individuals received their THVs more recently, so if they will suffer THV valve dysfunction, it may not have happened yet," he added.

In the early redo group, the indication for redo-TAVR was most often combined aortic THV stenosis and regurgitation (83.8%). Pure THV stenosis was seen in only 16.2% of patients.

For those with redo procedures after 1 year, THV stenosis was seen in 51 (37.0%) patients and regurgitation or combined stenosis-regurgitation in 86 (62.3%).

Device success using VARC-2 criteria was achieved in 85.1%, with no difference seen between those presenting within or beyond 1 year. Most failures were attributable to high residual gradients (14.1%) or regurgitation (8.9%).

No significant difference was seen in 30-day (94.6% and 98.5%) and 1-year survival (83.6% and 88.3%) in patients who presented within 1 year or later.

At 30-day and 1-year follow-up, residual gradients were 12.6 ± 7.5 mm Hg and 12.9 ± 9.0 mm Hg, respectively. High residual gradients (³20 mm Hg) were seen in about 14% of patients.

Aortic valve areas were 1.63 ± 0.61 cm2 at 30 days and 1.51 ± 0.57 cm2 at 1 year. Regurgitation was mild or less in 91% of patients at both time points.

Periprocedural complication rates were relatively low. There were three strokes (1.4%), one valve malposition (3.3%), two coronary obstructions (0.9%), and 20 new permanent pacemaker implants (9.6%). Importantly, no procedure-related mortality was seen, only one patient converted to open heart surgery, and symptomatic improvements were substantial.

"We are currently working on an analysis that compares TAVI-in-TAVI versus TAVI in surgical valves, and we are happy to see that it appears as if TAVI-in-TAVI outcomes don't fall short," said Landes. More analysis is also needed to see if perhaps some THVs work better or worse for redo procedures.

"We also want to understand which of the many combinations of heart valves available are better than others, thinking that supra-annular leaflets inside intra-annular leaflet devices may function differently than vice versa," said Landes.

Vinod Thourani, MD, chief of cardiovascular surgery at Piedmont Heart Institute, Atlanta, considers these new observational data "reassuring" and "robust," albeit with some limitations. He was first author on an editorial comment on this paper and spoke to | Medscape Cardiology.

"This is unadjudicated registry data but you can't lie about death and I feel good seeing that if you need a second TAVR inside of a TAVR, your mortality risk is pretty good," said Thourani.

That said, he questions whether these data can really be extrapolated to lower-risk patients. "I think this is an early snapshot and it's a relatively big sample, but it's a selected sample and we don't know how many patients needed redo TAVR and didn't get it or didn't want it," he added.

On the comforting side, there has been ongoing concern that a redo procedure that involves "propping open" a degenerated TAVR prosthesis's leaflets with a new TAVR valve may occlude the coronary ostium by closing the flow within the open cells.

"Luckily, the investigators show an extremely low risk of coronary obstruction of only 0.9% in an anatomically high-risk patient population," he said. This incidence, however, may increase as the use of TAVR rises in younger and less risky patients, he added.

Thourani would also like to see a longer follow-up on these patients. Median follow-up post redo TAVR was 15 months in this analysis.

"What I think we need to concentrate on as we do these studies is the life-long management of aortic stenosis wherein we try to minimize the overall number of invasive procedures as much as we can," said Thourani.

Landes reported no conflict of interest. Thourani reported he is an advisor and/or researcher for Abbott Vascular, Boston Scientific, and Edwards Lifesciences.

J Am Coll Cardiol. 2020;75:1882-1893, 1894-1896. Abstract, Editorial


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