Comparative analysis of postoperative outcomes and utilization trends for valve-in-valve transcatheter aortic valve implantation versus reoperative surgical aortic valve replacement

OBJECTIVE: To evaluate clinical outcomes, temporal trends, and age-related heterogeneity of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) versus redo surgical aortic valve replacement (re-SAVR) in patients with failed aortic bioprosthetic valves. METHODS: Patients undergoing ViV-TAVI or re-SAVR between 2011 and 2021 were identified from the Nationwide Readmission Database (NRD). Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline differences. Temporal trends in procedure utilization and patient age were assessed across calendar years. The primary outcome was all-cause mortality, including in-hospital, 30-day, and 6-month mortality. Secondary outcomes included in-hospital complications, all-cause readmission, and days alive and out of hospital (DAOH). Age-stratified and interaction analyses were performed. RESULTS: ViV-TAVI utilization increased significantly over time (p < 0.001), accompanied by a modest decline in patient age. Compared with re-SAVR, ViV-TAVI was associated with lower in-hospital mortality (OR 0.50, 95% CI 0.35-0.71; p < 0.001) and 30-day mortality (HR 0.60, 95% CI 0.43-0.83; p = 0.002), as well as lower risks of in-hospital stroke or transient ischemic attack, renal failure, and major bleeding (all p < 0.001). However, ViV-TAVI was associated with higher 30-day (HR 1.23, 95% CI 1.02-1.48; p = 0.031) and 6-month readmission (HR 1.25, 95% CI 1.07-1.46; p = 0.006). ViV-TAVI was also associated with higher DAOH at 30 days and 6 months (both p < 0.001). Interaction analyses suggested age-related heterogeneity for selected outcomes. CONCLUSIONS: ViV-TAVI use increased substantially and was associated with lower short-term mortality and fewer in-hospital complications, but higher readmission risk. Improved DAOH and potential age-related heterogeneity warrant further evaluation.