Transcatheter vs Surgical Replacement of Degenerated Bioprosthetic Aortic Valve: A Meta-Analysis of Propensity-Score-Matched Studies.

Introduction: Degeneration of bioprosthetic aortic valves is a common late complication. While redo surgical aortic valve replacement (redo-SAVR) has traditionally been the standard of care, transcatheter valve-in-valve implantation (ViV-TAVR) has emerged as a less invasive alternative. This meta-analysis aimed to compare outcomes between ViV-TAVR and redo-SAVR using propensity-score-matched studies. Methods: A systematic search of Cochrane CENTRAL, Scopus, MEDLINE (via PubMed) Embase, and Scopus was conducted from inception through to 1 September 2024. Propensity-score matched cohort studies comparing ViV-TAVR and redo-SAVR were included. Risk ratios (RRs) and mean differences (MDs) or standardised mean differences (SMD), as appropriate, were pooled using a random-effects model. Results: Thirteen propensity score–matched studies encompassing 16,223 patients (8,463 ViV-TAVR; 7,760 redo-SAVR) with a weighted mean follow-up of 16.6 months were included. Compared to redo-SAVR, ViV-TAVR was associated with significantly lower short-term all-cause mortality (RR: 0.47; 95% confidence interval [CI]: 0.34–0.66; p<0.0001), major bleeding (RR: 0.45; 95% CI: 0.33–0.59), acute kidney injury (RR: 0.56; 95% CI: 0.38–0.84), and shorter hospital stay (SMD: –0.79; 95% CI: –1.00 to –0.57). ViV-TAVR was also associated with a significantly lower incidence of new-onset atrial fibrillation (RR: 0.22; 95% CI: 0.13–0.37) but higher post-procedural mean transvalvular gradients (SMD: 0.45; 95% CI: 0.20–0.69). No significant differences were observed in 1- or ≥2-year mortality, stroke/transient ischaemic attack, myocardial infarction, permanent pacemaker implantation, or early readmission. Results remained consistent across sensitivity and subgroup analyses. Conclusion: ViV-TAVR offers significant short-term benefits over redo-SAVR, including lower early mortality and shorter hospitalisation. Long-term clinical outcomes remain comparable, while postprocedural mean gradients are higher after ViV-TAVR, underscoring the need for randomised trials and individualised patient selection to guide treatment decisions for degenerated bioprosthetic valves. © 2026 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)