Reintervention for Failed Aortic Bioprostheses: Distinct Patient Profiles for Redo Surgery and Valve-in-Valve TAVR in an All-Comers Cohort

<b>Background/Objectives</b>: Aortic valve therapy increasingly follows a lifetime management concept. As all bioprostheses ultimately degenerate, optimal outcomes rely on the appropriate selection and timing of treatment modality. This study evaluates outcomes of redo surgical aortic valve replacement (redo-SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) in a consecutive, unselected real-world cohort treated for bioprosthetic valve failure (BVF). <b>Methods</b>: A single-center retrospective analysis of all patients undergoing redo-SAVR or ViV-TAVR for BVF between June 2019 and December 2024 was conducted. The primary endpoint was survival at 30 days and at 1, 3, and 5 years; the secondary endpoint was time to reintervention. Cox proportional hazards models were used; proportionality was tested; subgroups were defined by indication and presence of concomitant procedures. <b>Results</b>: Eighty-three patients were included (redo-SAVR <i>n</i> = 42; ViV-TAVR <i>n</i> = 41). All active endocarditis cases were managed surgically. In isolated procedures, 30-day survival was 95.5% after redo-SAVR (100% when excluding endocarditis) and 100% after ViV-TAVR; 5-year survival was 81.3% and 94.1%, respectively (94.4% for isolated redo-SAVR excluding endocarditis). Because hazards were non-proportional and risk sets were sparse beyond 5 years, we fitted a time-split Cox model (0-5 years). In multivariable analysis, endocarditis (HR 4.45, 95% CI 1.16-17.04) and NYHA IV (HR 4.87, 95% CI 0.98-24.17)-not treatment modality-were associated with mortality. <b>Conclusions</b>: In a real-world, all-comers setting, early outcomes for isolated reinterventions were favorable with both pathways. Mortality patterns were case-mix driven-especially by endocarditis and the need for concomitant surgery. Accordingly, ViV-TAVR and redo-SAVR should be viewed not as competing procedures but as complementary, scenario-specific options within a lifetime management strategy.