A reappraisal of bioprosthetic structural valve degeneration after aortic valve replacement: Mode, outcome and effect of treatment

Background Structural valve degeneration (SVD) remains the main complication of aortic bioprosthesis. The study aimed to evaluate SVD mode, outcome and effect of treatment. Methods Patients with presumed aortic SVD by echocardiography in our institution between January 2010 and December 2016 were included. All-cause mortality, cardiovascular morbidity, and effect of treatment were assessed. Results After exclusion of 4 patients with others causes of increased gradients, 220 patients were analyzed (78 ± 9 years, 52% men). Regurgitant SVD ( n  = 94, 43%) occurred later than stenotic ( n  = 126, 57%) SVD (9.2 ± 3.7 vs. 7.9 ± 3.0 years; P  = 0.003). Patients with a regurgitant SVD were more symptomatic, had a larger bioprosthesis, and were more often referred to invasive management. Exclusive medical care (Med) was retained in 67 patients, redo-surgery in 89 and VinV in 64. Macroscopic examination of explanted bioprostheses ( n  = 71) demonstrated severe calcifications in 56.3%, mainly in stenotic SVD (71 vs. 42%, P  = 0.02), and leaflet tear in 28%. Overall survival at 35 months was significantly associated with the type of management (VinV: 85.3 ± 4.9%, redo-surgery 86.7 ± 3.8%, Med 60.1 ± 7.7%, P P  = 0.002), transvalvular maximal velocity, and invasive management (Redo-surgery: HR = 0.35 [95% CI: 0.15–0.81], P  = 0.014; VinV: HR = 0.32 [95% CI: 0.13–0.77], P  = 0.011) as compared to Med. Conclusion Structural valve degeneration remains a matter of concern. Regurgitant SVD occurs later than stenotic SVD which is characterized by a more severe calcification process. Redo-surgery and VinV are associated with a better outcome, independently of failure mode, and should be considered in most SVD patients. Although VinV was proposed to older and higher-risk patients, its effect on overall survival was comparable to redo-surgery in multivariable analysis.