Transcatheter Aortic Valve Replacement for Failed Small Surgical Bioprostheses

BACKGROUND: Data on the prognostic impact of failed surgical bioprosthetic size following valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) remain limited. OBJECTIVES: This study aimed to assess the impact of failed bioprosthetic size and subsequent prosthesis-patient mismatch (PPM) on midterm outcomes of ViV TAVR. METHODS: We analyzed patients who underwent ViV TAVR for degenerated surgical bioprostheses in the OCEAN-TAVI (Optimized transCathEter vAlvular iNtervention-transcatheter aortic valve implantation) registry. Patients were divided into 2 groups according to the true internal diameter (ID) of bioprostheses: the small bioprosthesis (SB) group (ID ≤20 mm) and the non-small bioprosthesis (NB) group (ID >20 mm). The primary endpoint was a composite of cardiovascular death or heart failure hospitalization at 3 years. Factors associated with severe measured PPM were also examined. RESULTS: Among 367 consecutive patients undergoing ViV TAVR (244 patients in the SB group vs 123 patients in the NB group), 30-day mortality was 0.5%. Severe PPM occurred in 16.9% of the entire cohort and was more prevalent in the SB group (21.3% in the SB group vs 8.3% in the NB group; P = 0.001). The SB group had a higher risk of cardiovascular death or heart failure hospitalization at 3 years (19.1% in the SB group vs 9.8% in the NB group; adjusted HR: 3.48; 95% CI: 1.11-10.87). The SB patients with severe PPM had the highest risk of the primary outcome at 3 years (SB with PPM 39.2% vs NB without PPM 11.0%; adjusted HR: 6.65 [95% CI: 1.95-22.71] compared with the NB group without PPM). Factors associated with severe PPM included larger body surface area, balloon-expandable valve implantation, and true ID ≤20 mm. CONCLUSIONS: ViV TAVR for small surgical bioprostheses was associated with worse clinical outcome, particularly in those with severe PPM. (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation [OCEAN-TAVI]; UMIN000020423).