The numbers reveal a striking pattern in how treatment is allocated. Repeat surgical aortic valve replacement, the traditional approach involving another round of open-heart surgery, accounted for 59 percent of the procedures, while valve-in-valve transcatheter aortic valve implantation, the less invasive catheter-based option, made up 41 percent. But the two groups were far from equivalent at the outset. Patients steered toward the transcatheter procedure were older, with a median age of 71 compared to 67 for the surgical group, and they carried a substantially heavier burden of disease.

The comorbidity gap was broad and consistent. Chronic lung disease affected 25 percent of transcatheter patients versus 10 percent of surgical patients. Peripheral artery disease was present in 21 percent versus 7 percent. Roughly a quarter of the transcatheter group had previously undergone percutaneous coronary intervention, compared to 11 percent of the surgical group. Severely reduced heart pumping function, defined as an ejection fraction of 30 percent or less, appeared in 10 percent of transcatheter patients but only 3 percent of surgical patients. Porcelain aorta, a calcified and fragile aorta that makes repeat surgery especially dangerous, was found in 7 percent of the transcatheter group and none of the surgical group. Collectively, these differences translated into a higher predicted operative risk, with a median EuroSCORE II of 6.2 percent for the transcatheter cohort against 4.6 percent for the surgical cohort.

When the researchers applied multivariable logistic regression to disentangle which factors independently drove the choice of the catheter-based procedure, several emerged as decisive. Each additional year of age raised the odds of receiving the transcatheter approach by 15 percent. Severely impaired left ventricular ejection fraction carried an odds ratio of 8.04, meaning patients with the weakest hearts were roughly eight times more likely to be routed to the catheter lab than to the operating theater. Chronic lung disease tripled the odds, with an odds ratio of 3.25, while the combination of obesity or cachexia and a history of prior coronary stenting each roughly tripled the likelihood as well.

The study also classified patients using the 2020 Dutch TAVI indication criteria, a national framework that stratifies candidates as intermediate, high, or prohibitive surgical risk. Because every patient in the cohort had already undergone cardiac surgery, all were considered at least intermediate risk by default. The allocation pattern was unambiguous: repeat surgery dominated among intermediate-risk patients, where it was used in 78 percent of cases, while the transcatheter procedure was favored in the high-risk category, accounting for 53 percent of procedures there, and was used in every single prohibitive-risk patient.

Survival outcomes told a nuanced story. Within the transcatheter cohort, estimated survival was 94.2 percent at 30 days, 89.6 percent at two years, and 74.4 percent at four years. The surgical cohort posted corresponding figures of 96.1 percent, 89.8 percent, and 88.4 percent. During the first two years, the curves were nearly identical despite the transcatheter group starting from a much sicker baseline. Only in years three and four did a gap open up, with the surgical cohort showing numerically better long-term survival. The authors are careful to stress that these figures describe what happened within each selected cohort, not what would happen if the treatments were compared head to head, since the groups differed so profoundly at baseline.

Risk stratification sharpened the picture further. Among intermediate-risk patients who received the transcatheter valve, four-year survival reached 93.0 percent, but it fell to 68.7 percent among those classified as high or prohibitive risk. In the surgical cohort, four-year survival was 90.9 percent for intermediate-risk patients and 84.7 percent for high-risk patients. Notably, 31 intermediate-risk surgical patients were still alive and under observation at the four-year mark, a finding the authors highlight as evidence that repeat open-heart surgery can deliver durable, excellent results in carefully chosen younger candidates.

The regression models probing mortality within each treatment group produced one of the study’s most clinically significant observations. Severe left ventricular dysfunction and chronic lung disease appeared on both sides of the ledger: they strongly predicted which patients would be selected for the transcatheter procedure, and they independently predicted death after surgical reintervention. In the surgical cohort, an ejection fraction of 30 percent or less carried a hazard ratio of 15.70 for all-cause mortality, though the authors caution this estimate rested on only five patients, two of whom died. Chronic lung disease carried a hazard ratio of 4.23 after surgery. In the transcatheter cohort, non-elective presentation and peripheral artery disease were the significant mortality predictors, with hazard ratios of 3.34 and 2.47 respectively.

The clinical backdrop to all of this is a quiet shift in valve surgery over the past two decades. Bioprosthetic valves, made from animal or human tissue rather than metal, are now used in roughly 85 percent of surgical aortic valve replacements because they spare patients a lifetime of blood-thinning medication. Their weakness is durability: structural degeneration typically sets in within 10 to 15 years, and often sooner in younger recipients. As tissue valves are increasingly offered to patients in their fifties and sixties with decades of life ahead, a growing cohort is expected to outlive its valves and face reintervention at ages where the decision carries maximum consequence for remaining lifespan.

The study’s authors are explicit about its limits. The registry did not capture the size and design of the failing prosthesis, the mechanism of valve failure, aortic root anatomy, or coronary obstruction risk, all of which weigh heavily in real heart-team deliberations and in long-term prognosis. Small failing prostheses, in particular, are a known hazard for the transcatheter approach because they can prevent full expansion of the new valve, causing prosthesis-patient mismatch; a prior registry analysis found a fourfold increase in one-year mortality for such patients. Nor did the study include patients whose failing valves were managed without intervention. The definitive answer may come from the ongoing REPEAT randomized trial, which is enrolling 890 patients under 75 with low-to-intermediate surgical risk and randomizing them to either strategy, with a five-year composite endpoint of death, stroke, heart attack, heart-failure hospitalization, or valve reintervention. Until those results arrive, this Dutch registry data suggests that neither approach is a default: the catheter-based option serves higher-risk phenotypes well in the short term, while carefully selected intermediate-risk patients can achieve excellent long-term survival with repeat surgery.

Subject of Research: Treatment selection and long-term survival after valve-in-valve TAVI versus redo surgical aortic valve replacement for failed bioprostheses in patients aged 50 to under 75

Article Title: 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

Article References: Kostea, A., van Niekerk, J., Uchoa de Assis, L., Adrichem, R., Timmermans, M. J. C., Tonino, P. A. L., Voskuil, M., de Weger, A., Porta, F., Kardys, I., Van Mieghem, N. M., Nuis, R.-J., & on behalf of the THI and Cardiothoracic Surgery Registration Committees of the Netherlands Heart Registration (2026). 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. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03045-8

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03045-8

Keywords: valve-in-valve TAVI, redo SAVR, bioprosthetic valve failure, aortic valve reintervention, Netherlands Heart Registration, structural valve degeneration, transcatheter aortic valve implantation, heart team decision-making, EuroSCORE II, long-term survival, left ventricular dysfunction, chronic lung disease