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Transcatheter versus Surgical Aortic Valve Replacement in Patients with Prior Mitral Valve Surgery
Jessica Forcillo, MD, John Kelly, Jose N. Binongo, PhD, Vasilis Babaliaros, MD, Robert A. Guyton, MD, Chandan Devireddy, MD, Bradley G. Leshnower, MD, James P. Stewart, MD, Vinod Thourani, MD.
Emory University, Atlanta, GA, USA.

BACKGROUND
Due to perceived technical challenges and potential for increased paravalvular leak (PVL), patients with prior mitral valve surgery (MVS) are typically excluded from transcatheter aortic valve replacement (TAVR) trials. Therefore, surgical aortic valve replacement (SAVR) remains the standard treatment in these patients. Our objective is to evaluate outcomes of patients with severe aortic stenosis with a prior MVS and now requiring a TAVR or SAVR.
METHODS
This was a retrospective study that reviewed a total of 68 patients with history of MVS who subsequently underwent TAVR (n=35) or SAVR (n=33) in a U.S. academic institution between January, 2005 and August, 2016.
RESULTS
The mean age was 73.26 11.89 years in the TAVR patients and 61.30 14.75 in the SAVR group (p=0.005). There was a similar distribution of males in each group (TAVR: 57.14% vs SAVR: 45.45%, p=0.34). The mean STS PROM scores were not significantly different between groups (TAVR: 11.04% vs SAVR: 6.71%, p=0.14). The mean time from prior MVS to subsequent TAVR or SAVR was similar (TAVR: 11.92 years vs SAVR: 9.78 years, p=0.22). Both TAVR and SAVR resulted in similar improvements in mean aortic valve gradient (p=0.69). There was no moderate/severe PVL in either the TAVR or SAVR groups. Duration of the procedure (p<0.0001), length of postoperative ICU stay (p=0.005), length of postoperative hospital stay (p<0.0001), postoperative atrial fibrillation (p=0.03), and postoperative blood transfusions (p<0.0001) were significantly less in the TAVR group. Finally, there was no significant difference in 30-day mortality (TAVR: 5.9% vs SAVR: 3.1%, p=0.7) and readmission within 30 days (TAVR: 3.1% vs SAVR: 12.9%, p=0.19) between the two groups.
CONCLUSION
This is one of the first reports on the early outcomes of TAVR in those with a prior MVS. When compared with SAVR, resource utilization was significantly improved in those undergoing TAVR. Early mortality was not significantly different in patients undergoing TAVR compared to those undergoing SAVR. We conclude that in appropriate high-risk patients, TAVR is as safe and effective as SAVR in patients with prior MVS.


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