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Long-Term Outcomes of Repeated Transcatheter Aortic Valve Replacement vs Transcatheter Aortic Valve Replacement
Thais Faggion Vinholo1, Jake Awtry1, Mansoo Cho2
1Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Background:
Comparative durability of subsequent procedures after transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to assess long-term outcomes of repeated TAVR vs TAVR explantation for bioprosthetic valve dysfunction after TAVR.
Methods:
Medicare beneficiaries undergoing aortic valve reintervention after index TAVR (January 2012-December 2020) were assigned to repeated TAVR or TAVR explantation categories. Exclusion criteria included endocarditis or reintervention during the same admission. Primary outcome was 5-year mortality; secondary outcomes included major adverse cardiovascular events (death, pacemaker placement, major bleeding, stroke, acute kidney injury, cardiac arrest). Time-to-event analyses used Kaplan-Meier curves. Adjusted outcomes were assessed by 1:1 propensity matching.
Results:
Of 1172 patients undergoing reintervention after TAVR, 70.6% had repeated TAVR and 29.4% had TAVR explantation. Repeated TAVR patients were older and more often female, with higher Charlson comorbidity score (all P < .05). Median follow-up was 29.2 months (27.7 months repeated TAVR, 32.3 months TAVR explantation). In the propensity score-matched cohorts, 30- and 90-day mortality was higher after TAVR explantation, but Kaplan-Meier estimated cumulative mortality was lower in TAVR explantation at 3 and 5 years (all P < .001). Survival curves crossed at approximately 9 months, after which TAVR explantation maintained a persistent advantage. The hazard ratio during the entire follow-up was 0.61 (95% CI, 0.49-0.75; P < .001). Similar survival patterns were observed across Charlson comorbidity stratification and after exclusion of concomitant procedures.
Conclusions:
Although repeated TAVR showed lower short-term mortality, long-term outcomes favored TAVR explantation. These findings suggest that for Medicare beneficiaries experiencing TAVR failure, there is a subset of patients who could benefit from TAVR explantation over repeated TAVR.
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