Edith Wolfson Medical Center, Holon, Israel; Tel-Aviv University, Tel-Aviv, Israel.
Rabin Medical Center, Tel-Aviv University, Tel-Aviv, Israel.
JACC Cardiovasc Interv. 2022 Aug 8;15(15):1543-1554. doi: 10.1016/j.jcin.2022.05.016. Epub 2022 Jul 13.
As transcatheter aortic valve (TAV) replacement is increasingly used in patients with longer life expectancy, a sizable proportion will require redo TAV replacement (TAVR). The unique configuration of balloon-expandable TAV (bTAV) vs a self-expanding TAV (sTAV) potentially affects TAV-in-TAV outcome.
The purpose of this study was to better inform prosthesis selection, TAV-in-TAV outcomes were assessed according to the type of initial and subsequent TAV.
Patients from the Redo-TAVR registry were analyzed using propensity weighting according to their initial valve type (bTAV [n = 115] vs sTAV [n = 106]) and subsequent valve type (bTAV [n = 130] vs sTAV [n = 91]).
Patients with failed bTAVs presented later (vs sTAV) (4.9 ± 2.1 years vs 3.7 ± 2.3 years; P < 0.001), with smaller effective orifice area (1.0 ± 0.7 cm vs 1.3 ± 0.8 cm; P = 0.018) and less frequent dominant regurgitation (16.2% vs 47.3%; P < 0.001). Mortality at 30 days was 2.3% (TAV-in-bTAV) vs 0% (TAV-in-sTAV) (P = 0.499) and 1.7% (bTAV-in-TAV) vs 1.0% (sTAV-in-TAV) (P = 0.612); procedural safety was 72.6% (TAV-in-bTAV) vs 71.2% (TAV-in-sTAV) (P = 0.817) and 73.2% (bTAV-in-TAV) vs 76.5% (sTAV-in-TAV) (P = 0.590). Device success was similar according to initial valve type but higher with subsequent sTAV vs bTAV (77.2% vs 64.3%; P = 0.045), primarily because of lower residual gradients (10.3 mm Hg [8.9-11.7 mm Hg] vs 15.2 mm Hg [13.2-17.1 mm Hg]; P < 0.001). Residual regurgitation (moderate or greater) was similar after bTAV-in-TAV and sTAV-in-TAV (5.7%) and nominally higher after TAV-in-bTAV (9.1%) vs TAV-in-sTAV (4.4%) (P = 0.176).
In selected patients, no association was observed between TAV type and redo TAVR safety or mortality, yet subsequent sTAV was associated with higher device success because of lower redo gradients. These findings are preliminary, and more data are needed to guide valve choice for redo TAVR.
随着经导管主动脉瓣置换术（TAV）在预期寿命较长的患者中的应用越来越多，相当一部分患者将需要再次进行 TAV 置换（TAVR）。球囊扩张式 TAV（bTAV）与自膨式 TAV（sTAV）的独特结构可能会影响 TAV-in-TAV 的结果。
本研究旨在更好地为假体选择提供信息，根据初始和后续 TAV 的类型评估 TAV-in-TAV 的结果。
使用倾向评分根据初始瓣膜类型（bTAV [n=115] 与 sTAV [n=106]）和后续瓣膜类型（bTAV [n=130] 与 sTAV [n=91]）对来自 Redo-TAVR 登记处的患者进行分析。
bTAV 失败的患者出现较晚（与 sTAV 相比）（4.9±2.1 年与 3.7±2.3 年；P<0.001），有效瓣口面积较小（1.0±0.7cm 与 1.3±0.8cm；P=0.018），且更常见的是主瓣反流（16.2%与 47.3%；P<0.001）。30 天死亡率为 2.3%（TAV-in-bTAV）与 0%（TAV-in-sTAV）（P=0.499）和 1.7%（bTAV-in-TAV）与 1.0%（sTAV-in-TAV）（P=0.612）；手术安全性为 72.6%（TAV-in-bTAV）与 71.2%（TAV-in-sTAV）（P=0.817）和 73.2%（bTAV-in-TAV）与 76.5%（sTAV-in-TAV）（P=0.590）。根据初始瓣膜类型，器械成功率相似，但随后的 sTAV 高于 bTAV（77.2%与 64.3%；P=0.045），这主要是因为残余梯度较低（10.3mmHg[8.9-11.7mmHg]与 15.2mmHg[13.2-17.1mmHg]；P<0.001）。bTAV-in-TAV 和 sTAV-in-TAV 后残余反流（中度或以上）相似（5.7%），而 TAV-in-bTAV 后（9.1%）略高于 TAV-in-sTAV（4.4%）（P=0.176）。
在选择的患者中，TAV 类型与再次 TAVR 的安全性或死亡率之间没有关联，但随后的 sTAV 与较低的再手术梯度相关，与更高的器械成功率相关。这些发现是初步的，需要更多的数据来指导再次 TAVR 的瓣膜选择。
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