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Original Investigation
July 9, 2014

Transcatheter Aortic Valve Implantation in Failed Bioprosthetic Surgical Valves

Author Affiliations
  • 1St Paul’s Hospital, Vancouver, British Columbia, Canada
  • 2German Heart Center, Munich, Germany
  • 3Deutsches Herzzentrum Berlin, Berlin, Germany
  • 4Washington Hospital Center, Washington, DC
  • 5Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
  • 6San Raffaele Scientific Institute, Milan, Italy
  • 7Asklepios Clinics St Georg, Hamburg, Germany
  • 8Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
  • 9University Heart Center Hamburg, Hamburg, Germany
  • 10Department of Interventional Cardiology at McGill University Health Centre, Montreal, Quebec, Canada
  • 11Sussex Cardiac Centre, Brighton, England
  • 12Hospital Bichat, Paris, France
  • 13Kerckhoff Heart Center, Bad Nauheim, Germany
  • 14Universitaetsklinikum Regensburg, Regensburg, Germany
  • 15Odense University Hospital, Odense, Denmark
  • 16University of Heidelberg, Heidelberg, Germany
  • 17Hemodynamic and Invasive Cardiology Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy.
  • 18University Hospital of Lausanne, Lausanne, Switzerland
  • 19Sheba Medical Center, Ramat Gan, Israel
  • 20Leids Universitair Medisch Centrum, Leiden, the Netherlands
  • 21Bern University Hospital, Bern, Switzerland
  • 22Royal Brompton Hospital, London, England
  • 23Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy
  • 24University Heart Center Dresden, Dresden, Germany
  • 25G. Pasquinucci Hospital, Massa, Italy
  • 26St George’s Hospital, London, England
  • 27Clinique Pasteur, Toulouse, France
  • 28Hopital Jacques Cartier, Massy, France
  • 29Ospedale Niguarda Ca’Granda, Milan, Italy
  • 30Azienda Ospedaliere Spedali Civili di Brescia, Brescia, Italy
  • 31Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
  • 32Hospital de Santa Cruz, Lisbon, Portugal
  • 33Clinical Institute S. Ambrogio, Milan, Italy
  • 34Rabin Medical Center and Tel Aviv University, Tel Aviv, Israel
JAMA. 2014;312(2):162-170. doi:10.1001/jama.2014.7246

Importance  Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed.

Objective  To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves.

Design, Setting, and Participants  Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (≤21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (≥25 mm; 31%). Implanted devices included both balloon- and self-expandable valves.

Main Outcomes and Measures  Survival, stroke, and New York Heart Association functional class.

Results  Modes of bioprosthesis failure were stenosis (n = 181 [39.4%]), regurgitation (n = 139 [30.3%]), and combined (n = 139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P = .005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P = .01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P = .001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (≤21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P = .02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P = .008).

Conclusions and Relevance  In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.