Treatment selection and long-term survival in patients aged 50 to < 75 years undergoing valve reintervention for failed surgical aortic bioprostheses: insights from the Netherlands Heart Registration

Abstract Objectives To describe real-world treatment allocation and observed long-term survival in patients aged 50 to < 75 years with failed surgical aortic bioprostheses who underwent reintervention through valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) or redo surgical aortic valve replacement (redo-SAVR) in the Netherlands. Methods Patients aged 50 to < 75 years who underwent ViV-TAVI or redo-SAVR for a failing surgical bioprosthesis between 2015 and 2020 were identified from the Netherlands Heart Registration. Baseline characteristics and Dutch surgical-risk categories were compared by treatment strategy. Multivariable logistic regression was used to identify factors associated with ViV-TAVI selection. Kaplan–Meier analysis described survival, and treatment-specific Cox models explored factors associated with all-cause mortality. Results Of 345 patients, 41% underwent ViV-TAVI and 59% redo-SAVR. Patients selected for ViV-TAVI were older (median 71 vs. 67 years, p < 0.001), had higher surgical risk (EuroSCORE II: 6.2% vs. 4.6%, p = 0.014), and had a greater comorbidity burden than redo-SAVR patients. Despite these baseline risk differences, estimated survival within the ViV-TAVI cohort was 94.2% at 30 days, 89.6% at 2 years, and 74.4% at 4 years; corresponding redo-SAVR estimates were 96.1%, 89.8%, and 88.4%. Left ventricular ejection fraction ≤ 30% and chronic lung disease were associated both with ViV-TAVI selection (OR: 8.04, 95% CI: 2.16–29.92 and OR: 3.25, 95% CI: 1.53–6.92, respectively) and with all-cause mortality after redo-SAVR (HR: 15.70, 95% CI: 2.49–67.14 and HR: 4.23, 95% CI: 1.53–13.14, respectively). Conclusion In this Dutch observational registry, ViV-TAVI was predominantly selected for patients with a higher-risk clinical phenotype, while redo-SAVR was more often used in lower-risk reintervention candidates and showed higher observed long-term survival. These data describe contemporary treatment selection and prognosis but do not establish comparative superiority of either strategy.