Background
As the use of bioprosthetic heart valves increases among younger patients with aortic stenosis (AS), lifetime management has become a central issue. Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is an established treatment option for degenerated bioprostheses. However, in contrast to native AS, the extent and prognostic relevance of cardiac damage in patients undergoing ViV-TAVI remain unclear.
Aims
This study aims to evaluate the impact of the cardiac damage stage on long-term outcomes following ViV-TAVI.
Methods
We retrospectively analyzed 815 patients with degenerated aortic bioprostheses who underwent ViV-TAVI across five German tertiary centers. Cardiac damage was classified according to a five-stage model based on the pre-procedural transthoracic echocardiography: stage 0 (no extravalvular cardiac damage), stage 1 (left ventricular damage), stage 2 (left atrial or mitral valve damage), stage 3 (pulmonary vasculature or tricuspid valve damage) or stage 4 (right ventricular damage). Long-term survival was evaluated using Kaplan-Meier analysis, and predictors of mortality were determined by multivariable Cox proportional hazards regression.
Results
Among 815 patients, the majority presented with advanced cardiac damage prior to ViV-TAVI (stage 0: 2.5%, stage 1: 4.5%, stage 2: 48.4%, stage 3: 27.1%, stage 4: 17.6%). During long-term follow-up of 7.9 years, mortality rates were 6% in stage 0, 16% in stage 1, 24% in stage 2, 25% in stage 3 and 26% in stage 4 (p for trend 0.01). Increased cardiac damage stage was independently associated with higher mortality (HR 1.29, 95% CI 1.07-1.55, p=0.007).
Conclusion
The extent of pre-existing cardiac damage prior to ViV-TAVI independently predicts long-term mortality. These findings extend the established prognostic relevance of cardiac damage staging from native AS to patients with failed bioprosthetic valves and underscore its potential value in lifetime management strategies and in determining the optimal timing of reinterventions.
