Transcatheter aortic valve implantation vs. surgery for failed bioprosthesis: a meta-analysis of over 20 000 patients

Objectives Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has gained popularity as a less invasive alternative to a redo surgical aortic valve replacement (redo-SAVR); which one is the preferred technique in these cases, however, remains a topic of debate, as the available data refer to retrospective studies with few patients or limited follow-up. The present metanalysis aimed to compare the short-term and long-term outcomes of the two techniques in the setting of a failed surgical bioprosthesis. Methods PubMed, MEDLINE, and Embase were searched on 10 November 2023 yielding 355 results (PROSPERO ID: CRD42023490612), of which 27 were suitable for meta-analysis. The primary outcomes were short-term and long-term all-causes and cardiovascular mortality. Logarithmic risk ratio (Log RR) and mean difference were used for categorical and continuous data, respectively. Results Both redo-SAVR and ViV-TAVI exhibited similar procedural and short-term mortality. However, ViV-TAVI demonstrated lower 1-year mortality [RR: 0.74, 95% confidence interval (CI) (0.57-0.96), P = 0.02], acute kidney injury (RR: 0.47, P < 0.001), bleeding (RR: 0.44, P < 0.001), stroke (RR: 0.70, P < 0.05), and new pacemaker implantation (RR: 0.69, P < 0.05). Conversely, redo-SAVR demonstrated more favorable mean postoperative aortic valve gradients [mean difference 2.59, 95% CI (0.86-4.31), P < 0.01]. Conclusion Short-term mortality was similar between the groups, but ViV-TAVI showed better survival at 1 year as well as reduced rates of acute kidney injury, bleeding, stroke, and pacemaker implantation. However, redo-SAVR leads to a better hemodynamic profile. Even if collected data come from retrospective studies, the present results could help to guide the choice of the best approach case-by-case according to the patient's clinical profile.