Transcatheter Aortic Valve Implantation in Redo Patients with Native Aortic Valve Stenosis - A Meta-Analysis
Alexander Meyer, Simon Sündermann, Axel Unbehaun, Semih Buz, Volkmar Falk, Jörg Kempfert.
German Heart Institute Berlin, Berlin, Germany.
OBJECTIVE: Redo surgical aortic valve replacement (SAVR) is technically challenging especially in the presence of a patent ITA graft. We investigated, whether transcatheter aortic valve implantation (TAVI) is advantageous in the redo setting.
METHODS: We performed a systematic review comparing SAVR with TAVI in redo cases with native aortic valve stenosis. Defined endpoints were 30-day-mortality, post-procedural stroke, necessity for pacemaker implantation, occurrence of a relevant paravalvular leakage (PVL), and in-hospital length of stay (LOS). Case-control studies and case series reports were not considered for analysis.
RESULTS: The Pubmed query at 2015-09-27 retrieved 337 records. After screening 328 were excluded: 251 hits did not address the research question, one article was not retrievable, and 76 studies were performed with a study design not eligible for inclusion. Overall we pooled nine studies with 1095 patients (TAVI n=548, SAVR n=547).
30-day-mortality did not differ between TAVI and SAVR (Figure1). In the TAVI cohort, stroke rate was markedly reduced. The difference was significant in the fixed effects model (FE), but not in the random effects model (RE) (FE: Risk Ratio 0.51, CI95 0.28-0.94, p=0.032; RE: Risk Ratio 0.58, CI95 0.28-1.18, p=0.13). Necessity for pacemaker implantation was almost double in TAVI patients compared to SAVR (FE: Risk Ratio 1.95, CI95 1.28-2.97, p=0.0018; RE: Risk Ratio 2.08, CI95 0.85-5.07, p=0.11). Only four out of the nine studies reported data on PVL. Pooling these data showed no significant difference in relevant PVL (FE: p=0.12; RE: p=0.45). Similarly, LOS was only reported in 5 studies, and pooled results did not differ (FE: p=0.78; RE: p=0.20).
CONCLUSIONS: For redo patients with native aortic valve stenosis TAVI can be considered a safe alternative with similar short term outcomes compared to SAVR in high-risk patients. TAVI offers a safe and effective treatment option in a challenging patient cohort. A randomized controlled trial in a lower risk redo population seems warranted.
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