Meta-analysis of Valve-in-Valve Transcatheter versus Redo Surgical Aortic Valve Replacement

The objective of this study was to determine whether valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) is associated with better survival than redo surgical aortic valve replacement (SAVR) in patients with degenerated aortic valve bioprostheses, and we performed a meta-analysis of comparative studies.

To identify all comparative studies of VIV-TAVI versus redo SAVR; MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched through October 2017. For each study, data regarding all-cause mortality in both the VIV-TAVI and redo SAVR groups were used to generate odds ratios (ORs). To assess selection bias, we generated ORs and (standardized) mean differences (MDs) for baseline characteristics. Study-specific estimates were combined in the random-effects model.

Of 446 potentially relevant articles screened initially, 6 reports of retrospective comparative studies enrolling a total of 498 patients were identified. Pooled analyses of baseline characteristics demonstrated no statistically significant differences in the proportion of women, patients with diabetes mellitus, patients with coronary artery disease, and patients with baseline New York Heart Association functional class of ≥III; baseline ejection fraction; and predicted mortality between the VIV-TAVI and redo SAVR groups. Patients in the VIV-TAVI group, however, were significantly older (MD, 4.20 years) and had undergone prior coronary artery bypass grafting more frequently (OR, 2.19) than those in the redo SAVR group. Main pooled analyses demonstrated no statistically significant differences in early (30 days or in-hospital) (OR, 0.91; p = 0.83) and midterm (180 days-3 years) all-cause mortalities (OR, 1.42; p = 0.21) between the VIV-TAVI and redo SAVR groups.

In patients with degenerated aortic valve bioprostheses, especially elderly or high-risk patients, VIV-TAVI could be a safe, feasible alternative to redo SAVR. The lack of randomized data and differences in baseline characteristics in the present analysis emphasize the need for prospective randomized trials.