CardioExchange Archive

With the increasing use of bioprosthetic aortic valves in aortic valve replacement surgery, more and more physicians and patients will inevitably be faced with the dilemma of how best to treat degenerated valves. Although surgical reoperation is considered the best solution, many patients are too old and frail for surgery. Transcatheter aortic valve implantation (TAVI) has been proposed for use in this situation, though the risks and benefits have not as yet been well defined.

Now, a new study in JAMA provides information on 459 patients with failed bioprosthetic valves who underwent TAVI.  The investigators in the VIVID (Valve-in-Valve International Data) Registry report that the death rate was 7.6% at one month and 16.8% at one year. A total of 39.5% of valve failures were due to stenosis, 30.3% due to regurgitation, and 30.3% due to a combination of the two. Survival was lowest in the stenosis group and in patients with small valves compared with patients with intermediate-size or large valves.

David Hillis offered an insightful perspective on this paper:

Inevitably, some recipients of bioprosthetic valves experience prosthetic valve failure and need some form of re-do procedure.  A repeat surgical AVR carries a substantial risk, since (1) these patients are often quite elderly, and (2) any re-operation potentially can be high-risk (any time one cuts into a chest that has been cut on previously, surprises sometimes await — i.e., stuff is stuck to other stuff that makes the procedure complicated and difficult).  Bioprosthetic valve failure is not common — but it does occur, particularly with prostheses that have been in place for >10-12 years.  Having a nonsurgical alternative to repeat AVR is attractive.  This registry experience simply concludes that performing TAVI in these individuals is a reasonable alternative.  Is it better than repeat surgical AVR?  Obviously, this paper doesn’t answer that question.

In short, I would term this a “feasibility study” — doing TAVR on these subjects is feasible.”