Redo TAVI With Balloon-Expandable Valves Shows Promise in Treating Failed Transcatheter Aortic Valves

Registry data has revealed that redo transcatheter aortic valve implantation (TAVI) using balloon-expandable valves effectively treats stenosis or regurgitation in failed transcatheter aortic valves among older patients. This approach demonstrates minimal complications, comparable to those seen in native TAVI procedures. The study published in Lancet by Makkar RR and colleagues brings valuable insights into the management of failed transcatheter heart valves.

Key findings from the study:

● Patient Demographics: The study included 350,591 consecutive patients who underwent TAVI with balloon-expandable valves. Among the 1,320 patients who underwent redo TAVI, the average age was 78 years, with 42.3% being female. The mean predicted surgical risk of 30-day mortality was 8.1%.

● Safety and Complications: Analysis of 1,320 propensity-matched pairs showed that patients undergoing redo TAVI experienced low rates of complications, including coronary compression or obstruction (0.3%), intraprocedural death (0.6%), and conversion to open-heart surgery (0.5%). These rates were similar to those observed in native-valve TAVI procedures.

● Outcomes: There were no significant differences between the redo and native TAVI groups in terms of death at 30 days (4.7% vs. 4.0%) or at one year (17.5% vs. 19.0%) and stroke at 30 days (2.0% vs. 1.9%) or one year (3.2% vs. 3.5%). Aortic valve gradients were higher in the redo TAVI group compared to the native TAVI group at one year (15 vs. 12 mm Hg).

● Valve Durability: The study noted improved valve durability over time. However, a proportion of patients (18.4%) in the redo TAVI group were left with residual gradients of at least 20 mm Hg at discharge.

● Patient Selection: Redo TAVI was considered safe and effective in this study, but it was emphasized that the patient population selected for the procedure might represent those who were at high risk for surgery or had anatomically favourable conditions for redo TAVI.

While the study provides valuable insights into the safety and efficacy of redo TAVI with balloon-expandable valves, it is noted that the patient population studied may not reflect all scenarios, particularly those involving late failure of transcatheter valves. Further research is needed to address long-term outcomes and identify the best strategies for managing patients with failed transcatheter valves.

Experts believe that as transcatheter valve technology advances, the lessons learned from redo TAVI procedures will contribute to improved patient care, especially in younger and lower-risk populations. The study highlights the importance of thorough patient selection and

careful monitoring during redo TAVI procedures. Future research may focus on optimizing valve combinations and planning strategies for the best patient outcomes.

The study, published in The Lancet, suggests that redo TAVI with balloon-expandable transcatheter valves could be a reasonable option for selected patients who are deemed appropriate for redo TAVI by their heart teams. However, it also underscores the need for continued research in this evolving field of cardiac interventions.

Reference:

Makkar RR, Kapadia S, Chakravarty T, et al. Outcomes of repeat transcatheter aortic valve replacement with balloon-expandable valves: a registry study. Lancet. 2023