Related Experiment Video
Updated: Jun 2, 2025
Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement
Published on: December 11, 2017
Clinical Characteristics and Outcomes of Patients Undergoing 3 Aortic Valve Interventions: The THIRD Multicenter
Giuseppe Tarantini1, Gilbert H L Tang2, Thomas Pilgrim3
1Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
Insights
Third aortic valve interventions are increasingly common, primarily due to structural valve deterioration. The most frequent sequence was surgical aortic valve replacement followed by transcatheter aortic valve replacement, with favorable short-term outcomes.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Aortic valve disease management, particularly repeat interventions, is a growing clinical concern.
- While risks of a second aortic valve intervention are known, data on third interventions remain limited.
Purpose of the Study:
- To investigate the clinical characteristics, indications, and outcomes of patients undergoing a third aortic valve intervention.
- To analyze procedural sequences and identify factors influencing intervention choice in the THIRD registry.
Main Methods:
- Retrospective, multicenter, international study (THIRD registry) of patients undergoing a third aortic valve procedure (surgical or transcatheter).
- Exclusion of patients with two interventions during the same admission.
- Adjudication of baseline characteristics, procedural details, and outcomes per Valve Academic Research Consortium criteria.
Main Results:
- 51 patients from 11 centers were analyzed; 65% received transcatheter aortic valve replacement (TAVR) and 35% surgical aortic valve replacement (SAVR) as their third intervention.
- Structural valve deterioration (SVD) was the primary indication (76%) for the third procedure.
- The most common sequence was SAVR-SAVR-TAVR (37%); 30-day device success was 85% for TAVR and 94% for SAVR.
Conclusions:
- Structural valve deterioration is the main driver for third aortic valve interventions.
- SAVR-SAVR-TAVR represents the most frequent procedural pathway, while TAVR-TAVR-TAVR is less common.
- Short-term outcomes in this cohort were encouraging, warranting further long-term investigation.
Background:
Lifetime treatment of aortic valve disease is a matter of increasing debate. Although the risks of a second aortic valve intervention are recognized, little attention has been given to the challenges of a third.
Objectives:
This study delves into the clinical characteristics, indications, and outcomes of patients undergoing 3 aortic valve interventions.
Methods:
The THIRD (THree aortIc Reinterventions for valve Disease) registry is a retrospective multicenter, international study of patients who underwent a third procedure on the aortic valve, either surgically or transcatheter-based. Patients undergoing 2 aortic procedures during the same hospital admission were excluded. Baseline characteristics, timing, and mode of bioprosthetic failure, sequence of the procedures, and clinical outcomes were adjudicated according to the Valve Academic Research Consortium criteria.
Results:
A total of 51 patients from 11 centers were enrolled in this study. Median follow-up time was 565 (314-1,560) days. Eighteen patients (35%) underwent surgical aortic valve replacement (SAVR), and 33 of 51 patients (65%) underwent transcatheter aortic valve replacement (TAVR) as the third intervention. Mean age was 69 ± 14 years, 20 of 51 patients (39%) were female. STS score was 5.0% (Q1-Q3: 3.3%-7.0%). In all TAVR cases, the indication for the first intervention was severe aortic stenosis, as was the indication in 31 of 45 (69%) of SAVR cases (33% bicuspid). The most prevalent procedure sequence was SAVR-SAVR-TAVR (19/51, 37%), followed by SAVR-SAVR-SAVR (10/51, 20%) and SAVR-TAVR-TAVR (10/51, 20%). TAVR-TAVR-TAVR was performed in 4 of 51 cases (8%). The primary indications for a third intervention included structural valve deterioration (SVD) (39/51, 76%), non-SVD (8/51, 16%), and endocarditis (2/51, 4%). Excluding patients with a mechanical prosthesis, predictors of SAVR as third intervention included a lower STS score (OR: 0.58; 95% CI: 0.34-0.98; P = 0.04) and the presence of moderate or severe prosthesis-patient mismatch (OR: 44.8; 95% CI: 2.41-122.00; P = 0.01). Thirty-day device success was 85% for TAVR and 94% for SAVR.
Conclusions:
In the THIRD registry, SVD emerged as the predominant indication for a third aortic valve procedure. The most frequent procedure sequence was SAVR-SAVR-TAVR, whereas TAVR-TAVR-TAVR was less common. Although the short-term outcomes in our selected cohort were favorable, further investigation is needed.
