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. 2023 Sep 17:16:93-102.
doi: 10.1016/j.xjon.2023.07.026. eCollection 2023 Dec.

Impact of reintervention after index aortic valve replacement on the risk of subsequent mortality

William Y Shi  1 , Alexandra Malarczyk  2 , Ryan A Watson  3 , Prem Patel  2 , Paige Newell  2 , Jake Awtry  2 , Siobhan McGurk  2 , Tsuyoshi Kaneko  4
Affiliations

Impact of reintervention after index aortic valve replacement on the risk of subsequent mortality

William Y Shi et al. JTCVS Open. .

Abstract

Objectives: The use of bioprosthetic aortic valve replacement (AVR) is inherently associated with a risk of structural valve degeneration (SVD) and the need for aortic valve (AV) reintervention. We sought to evaluate whether AV reintervention, in the form of repeat surgical AVR (SAVR) or valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), negatively affects patients' subsequent long-term survival after index SAVR.

Methods: We identified patients who had undergone bioprosthetic SAVR from 2002 to 2017 at our institution. Median longitudinal follow-up after index SAVR was 7.3 years (10.9 years for those with and 7.2 years for those without AV reintervention), and median follow-up after AV reintervention was 1.9 years. Cox regression analyses using AV reintervention (re-SAVR and ViV-TAVR) as a time-varying covariate were used to determine the impact of reintervention on subsequent survival.

Results: Of 4167 patients who underwent index SAVR, 139 (3.3%) required AV reintervention for SVD, with re-SAVR being performed in 65 and ViV-TAVR in 74. Median age at the index SAVR was 73 years (interquartile range, 64-79 years), and 2541 (61%) were male. Overall, there were total of 1171 mortalities observed, of which 13 occurred after re-SAVR and 9 after ViV-TAVR. AV reintervention was associated with a greater risk of subsequent mortality compared with those patients who did not require AV reintervention (hazard ratio, 2.53; 95% confidence interval, 1.64-3.88, P < .001). This increased risk of subsequent mortality was more pronounced for those who received their index AVR when <65 years of age (hazard ratio, 5.60; 95% confidence interval, 2.57-12.22, P < .001) versus those ≥65 years (2.06, 1.21-3.52, P = .008). Direct comparison of survival between those who underwent re-SAVR versus ViV-TAVR showed 5-year survival to be comparable (re-SAVR: 74% vs ViV-TAVR: 80%, P = .67).

Conclusions: Among patients receiving bioprosthetic AVR, an AV reintervention for SVD is associated with an increased risk of subsequent mortality, regardless of re-SAVR or ViV-TAVR, and this risk is greater among younger patients. These findings should be balanced with individual preferences at index AVR in the context of patients' lifetime management of aortic stenosis.

Keywords: aortic valve replacement; structural valve degeneration; transcatheter aortic valve replacement.

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Conflict of interest statement

Dr Kaneko is a consultant for Edwards Life Sciences, Medtronic, 4C Medical, Abbott, and Baylis. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

None
After AVR, AV reintervention is associated with an increased risk of mortality.
Figure 1
Figure 1
Flow diagram illustrating the study population. AVR, Aortic valve replacement; CABG, coronary artery bypass grafting; AV, aortic valve; SVD, structural valve degeneration; MV, mitral valve; VIV-TAVR, valve-in-valve transcatheter aortic valve replacement.
Figure 2
Figure 2
Cumulative incidence curves demonstrating the incidence of the competing events of undergoing reoperative surgical aortic valve replacement (SAVR), valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), death, or remaining alive without undergoing a repeat procedure after index AVR. 95% confidence intervals are shown in parentheses. AVR, Aortic valve replacement.
Figure 3
Figure 3
Comparison of survival after reoperative surgical aortic valve replacement (re-SAVR) versus valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). 95% confidence intervals are shown in parentheses.
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