Repeat TAVR Central to Aortic Valve Disease Lifetime Strategy

Fran Lowry

August 02, 2021

Repeat transcatheter aortic valve replacement (TAVR), that is, TAVR performed within a failed TAVR valve, is associated with about half the short-term mortality of an alternative procedure, TAVR-valve explantation and replacement with a surgical aortic-valve prosthesis, suggests an observational study based on Medicare data.

But mortality at 1 year was similar for both types of prosthesis-replacement procedures.

Comparison of TAVR-in-TAVR and surgical explantation in the analysis, despite case-matching based on 21 clinically important variables, is fraught with selection biases, acknowledges the report on the study published August 2 in JACC: Cardiovascular Interventions.

However, "Given the favorable short-term outcome" and its increasingly common use in younger patients, "repeat TAVR will be an important option for aortic valve reintervention in the lifetime management of aortic valve disease in appropriately selected patients," write the authors, led by Edward D. Percy, MD, MSc, of Brigham and Women's Hospital, Boston, and University of British Columbia, Vancouver, Canada, and Morgan T. Harloff, MD, of Brigham and Women's Hospital.

"Repeat TAVR is a safe procedure. That's the main message we want to send," senior author Tsuyoshi Kaneko, MD, Brigham and Women's Hospital, told theheart.org | Medscape Cardiology.

"But there is a caveat," he said. Mortality in the study, undertaken to examine real-world experience in a national population-based data set, Kaneko noted, was higher than that reported earlier this year from a registry study with more than 1000 cases.

In the current analysis based on 133,250 Medicare patients who underwent primary TAVR from 2012 to 2017, 617 (0.46%) underwent repeat TAVR a median of 154 days after their initial procedure; their mean age was 81 years and 42% were women.

The repeat-TAVR cohort was a fairly sick group in which 82% had congestive heart failure at the time of hospitalization, 61.8% had chronic kidney disease, 36.6% had chronic pulmonary disease, and 25.3% had high-risk Charlson comorbidity scores.

Mortality was 6.0% at 30 days and 22.0% at 1 year. Rates of stroke and pacemaker insertion were 1.8% and 4.2% at 30 days.

The researchers also found that both 30-day and 1-year mortality following repeat TAVR were significantly lower in patients who had their primary TAVR between 2015 and 2017 compared with those who received it in an earlier era, from 2012 to 2014.

Mortality at 30 days for the earlier group was 8.7% and at 1 year was 28.2%. Those numbers compared to 4.6% and 19.0%, respectively, for the patients treated from 2015 to 2017.

"In the later era the outcomes were much better," Kaneko said. "This means that we are getting more experience. The mortality is coming down."

The researchers also compared repeat TAVR with surgical TAVR-valve explantation over the same time period.

Repeat TAVR was associated with lower 30-day mortality compared with TAVR explantation (6.2% vs 12.3%; P = .050). But 1-year mortality was similar in both groups at 21.0% and 20.8%, respectively. Repeat TAVR was also associated with lower bleeding complications, shorter length of hospital stay, and a lower risk of major adverse cardiac events at 30 days.

"We have been doing the procedure for about 10 years. A lot of the patients who were analyzed in our study had TAVRs back in the old days — in 2012 and 2013," Kaneko said. "They were very sick patients even when they received their first TAVR, and they were even sicker the second time. That probably contributed to the higher mortality seen in our study compared with the international registry."

The number of repeat TAVR procedures will surely increase as TAVR is performed in younger and lower-risk individuals, he observed.

"When you put in a TAVR in a 65-year-old, they will come back at about age 75, and then what do you do? We are at the dawn of understanding and refining repeat TAVR after the failed first valve. It's something we will increasingly have to deal with," Kaneko said.

TAVR is increasingly recommended in younger patients, most of whom will outlive their transcatheter heart valve, so practice is gradually shifting toward management of aortic stenosis as lifetime strategy, observe Giuseppe Tarantini, MD, PhD, and Luca Nai Fovino, MD, PhD, from University of Padua Medical School, Italy, observe in an accompanying editorial.

"When approaching a patient with aortic stenosis whose life expectancy exceeds the anticipated durability of valve prosthesis, the Heart Team should envisage the impact of the first intervention on future therapeutic options," Tarantini and Fovino write.

Repeat TAVR "will represent a less invasive, valuable therapeutic option in the lifetime strategy of patients with aortic stenosis, but it will not be possible for every patient. We must be aware that the first therapeutic decision is the game changer for the long-term future of our patients with aortic stenosis. The first cut will be the deepest," they conclude.

Kaneko disclosed speaking for Edwards Lifesciences, Medtronic, Abbott, and Baylis Medical, and consulting for 4C Medical. Tarantini disclosed lecture fees from Boston Scientific, Edwards Lifesciences, and Medtronic. Percy and Nai Fovino have disclosed no relevant financial relationships.

JACC Cardiovasc Interv. 2021;14:1717-26, 1727-30. Report, Editorial

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