The use of transcatheter aortic valve replacement (TAVR) as the first valve strategy “may not be warranted” in patients with life expectancy beyond the TAVR valve and unsuitable anatomy for redo-TAVR, reports a new study. The study, published online Monday and in the April 24 issue of JACC: Cardiovascular Interventions, sought to define comparative risk of surgical aortic valve replacement (SAVR) after prior TAVR or SAVR – finding that compared with redo SAVR after SAVR, redo SAVR after TAVR is associated with an increased risk of mortality. Led by Robert B. Hawkins, MD, MSc, from the University of Michigan, the team noted that the dramatic growth in TAVR has resulted in an overall increase in aortic valve replacements but that such growth has generally come from TAVR, at the expense of SAVR. “Unfortunately, the implementation of TAVR has outpaced our understanding of the true long-term consequences of our decisions. This is particularly true for younger patients,” they said. “Given the rapid expansion of TAVR in younger patients, attention has shifted toward lifetime management strategies,” they noted, adding that while the feasibility of redo-TAVR is becoming clearer, concerns are emerging regarding the use of SAVR reoperation after TAVR. Reintervention questions: SAVR-first or TAVR-first “One large question for patients needing a valve replacement is whether their life expectancy is beyond the durability expectations for their planned prosthesis choice,” said Hawkins and colleagues, noting that given the combination of structural valve degeneration (SVD), paravalvular leak, and endocarditis factors, “there should be a reasonable chance of reintervention in patients with a life expectancy over 10 years.” “The question for these patients is how best to decide on a SAVR- vs TAVR-first approach,” they said, adding that although the technology for transcatheter leaflet laceration to facilitate redo-TAVR is emerging, the move toward higher implantation levels to avoid the need for a permanent pacemaker also makes this more difficult, due to insufficient valve-to-coronary distance. “Meanwhile, redo SAVR after de novo SAVR can be performed at high-volume centers with a similar risk of mortality as initial SAVR,” said the authors. “However, this may not be the case for redo-SAVR after TAVR,” they said, citing implications for a TAVR-first approach in patients without aortic root anatomy clearly amenable to redo-TAVR. “The purpose of this study was to evaluate the risk of redo SAVR with prior TAVR (TAVR-SAVR) in comparison with prior SAVR (SAVR-SAVR).” Study details Hawkins and colleagues analyzed data on patients undergoing bioprosthetic SAVR after TAVR and/or SAVR from the Society of Thoracic Surgeons database (2011-2021). The primary outcome was operative mortality, while risk adjustment using hierarchical logistic regression and propensity-score matching for isolated SAVR cases were performed. The team found that of 31,106 SAVR patients, 1,126 had prior TAVR (TAVR-SAVR), 674 had prior SAVR and TAVR (SAVR-TAVR-SAVR), and 29,306 had prior SAVR (SAVR-SAVR). Yearly rates of TAVR-SAVR and SAVR-TAVR-SAVR increased over time, whereas SAVR-SAVR was stable, they noted, adding that TAVR-SAVR patients were older, with higher acuity, and with greater comorbidities than other cohorts. “In this nationwide analysis, the rate of SAVR-SAVR increased in early years but has been stable over the last 5 years. Meanwhile, the rates of TAVR-SAVR and SAVR-TAVR-SAVR are increasing by 32 to 42 cases/year,” they noted. Further analysis found the unadjusted operative mortality rate was 17% for TAVR-SAVR, 12% for SAVR-TAVR-SAVR, and 9% for SAVR-SAVR cohorts (P < 0.001), and that compared with SAVR-SAVR, risk-adjusted operative mortality was significantly higher for TAVR-SAVR (odds ratio [OR]: 1.53; P = 0.004), but not SAVR-TAVR-SAVR (OR: 1.02; P = 0.927). After propensity-score matching, operative mortality of isolated SAVR was 1.74 times higher for TAVR-SAVR than SAVR-SAVR patients (P = 0.020). Shifting focus Writing in an accompanying editorial, Giuseppe Tarantini, MD, PhD, and Tommaso Fabris, MD, from the University of Padua Medical School, Italy, noted that a primary focus of severe aortic stenosis management has been the choice between TAVR and SAVR as the first intervention. “This is related to the fact that survival after aortic intervention (both SAVR and TAVR) of older as well as high–surgical risk patients is shorter than the durability of bioprostheses in the vast majority of cases,” they said. “Considering the longer life expectancy of today’s TAVR patients and the expansion of TAVR-in-SAVR procedures, the treatment focus should now shift from the first to the second aortic intervention (ie, to the treatment of bioprosthetic failure), regardless of whether the first intervention is SAVR or TAVR,” they warned. As a result, the editorialists suggested that the role of the heart team “needs further evolution,” – adding that more accurate prediction models for life expectancy should now be developed, in order to identify subjects who will live longer than their bioprosthetic valves. “We [also] need to anticipate at the time of the first aortic intervention the lifetime sequence of possible permutations of reinterventions, on the basis of specific patient characteristics. This ideally means that when transcatheter approach is the first intervention, future permutations in case of SVD have better options than TAVR explantation,” they said. Sources: Hawkins RB, Deeb GM, Sukul D, et al. Redo Surgical Aortic Valve Replacement After Prior Transcatheter Versus Surgical Aortic Valve Replacement. JACC Cardiovasc Interv 2023;16:942-953. Tarantini G, Fabris T. Redo Aortic Valve Interventions: A Good Start Is Half the Job to Subsequent Permutations. JACC Cardiovasc Interv 2023;16:954-957. 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