Surgical explantation after TAVR failure: What cardiologists, and patients, should know
When transcatheter aortic valve replacement (TAVR) fails—often due to structural valve degeneration (SVD) or the need for additional interventions—the patient either has to undergo redo TAVR or have the device removed altogether. A new analysis in JACC: Cardiovascular Interventions examined patient outcomes after TAVR explantation, highlighting the seriousness of such a procedure and providing new context for healthcare providers and patients alike.
“As TAVR expands to younger, lower risk patients, there is limited data on outcomes of surgical explantation following TAVR,” wrote first author Vinayak N. Bapat, MD, of Abbott Northwestern Hospital in Minneapolis, Minnesota, and colleagues.
Bapat et al. tracked data from the EXPLANT-TAVR registry, focusing on 269 patients from 42 different facilities who underwent TAVR explantation from November 2009 to September 2020. The mean patient age was 72.7 years old, and the median time to explantation was 11.5 months. The median follow-up duration was 29.8 months.
While 25.9% of patients were viewed as low-risk patients at the time of their procedure, the median Society of Thoracic Surgeons risk at the time of explantation was 5.6%. Nearly 51% of TAVR explantation procedures were performed on patients who had received balloon-expandable valves.
Overall, the intraoperative mortality rate for explantation was just 0.7%. The survival rate for the entire patient population at the most recent follow-up was 76.1%.
In-hospital mortality was 11.9%, 30-day mortality was 13.1% and one-year mortality was 28.5%. The in-hospital, 30-day and one-year stroke rates were 5.9%, 8.6% and 18.7%, respectively.
Redo TAVR was not a treatment option for 34% of patients included in the study, the author added.
“TAVR explantation, in contrast, can be offered to most patients who are surgical candidates, but as demonstrated in this study, the risks are higher than isolated first-time surgical aortic valve replacement,” they wrote. “Yet the elevated mortality and morbidity rates in TAVR explantation may simply reflect older age, high-risk patient profiles, and early surgical experience.”
Explantation was due to endocarditis 43.1% of the time. In 20.1% of cases, meanwhile, the cause was SVD. Other reasons included paravalvular leak (18.2%) and prosthesis-patient mismatch (10.8%).
“TAVR explantation is emerging as a useful option for transcatheter heart valve failure, but experience thus far has raised concerns over outcomes and challenges,” the authors wrote. “The present study is the largest comprehensive, multicenter study that demonstrates significant mid-term mortality and morbidity associated with TAVR explantation. A randomized trial between redo TAVR and TAVR explantation may be considered in patients with low surgical risk, with a focus on mid-term outcomes and anticoagulation requirements.”
Read the full analysis here.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.