When valves fail: Surgeons share advice for treating high-risk patients with TAVR explant and SAVR
When a heart patient’s transcatheter aortic valve replacement (TAVR) valve fails, redo TAVR is not always a feasible option. TAVR explantation and subsequence surgical aortic valve replacement (SAVR) are typically the answer in these cases, but this approach is associated with certain risks.
Researchers out of the University of Alabama at Birmingham (UAB) have found considerable success performing TAVR explant and subsequent SAVR. The group shared its experience in The Annals of Thoracic Surgery.[1]
“TAVR explantation is now one of the fastest growing cardiac surgery procedures in the country, with an expected exponential increase in surgical explants,” wrote first author Sasha A. Still, MD, an assistant professor in the division of cardiothoracic surgery at UAB, and colleagues. “Published data demonstrate a high rate of short and mid-term adverse outcomes in experienced hands, prompting new concern and initiative to reduce explant-related morbidity and mortality and temporize risk in the lifetime management of aortic stenosis. We describe a very high-risk population of patients who underwent TAVR explant with SAVR at our institution with excellent short-term outcomes and acceptable mid-term outcomes.”
Reviewing the TAVR explant patients and procedures
Still et al. reviewed data from more than 2,000 patients who underwent TAVR at their facility, focusing on 33 who required the TAVR explant and subsequent SAVR. The mean age was 75 years old, 58% were male and the mean Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score was 5.49%. One in three patients had received a pacemaker prior to TAVR explant. Patients had originally received a variety of valves, including those made by both Medtronic and Edwards Lifesciences.
The median time from TAVR to TAVR explant was 815 days. The most common indication for TAVR explant was bioprosthetic degeneration, followed by endocarditis, severe paravalvular leak and ventricular septal defect. All patients were unsuitable for redo TAVR procedures, according to a multidisciplinary heart team reviewing their case prior to treatment. Only bioprosthetic SAVR valves were implanted as part of these procedures.
In all instances, the two procedures were performed via median sternotomy with central aortic and venous cannulation, cardiopulmonary bypass and myocardial arrest with intermittent retrograde and antegrade cold blood cardioplegia. The failed TAVR valve was removed using the “peel-away” or “roll” technique, though some differences do exist based on the exact valve type. Root repair was required in a total of three cases. No patients required a Bentall procedure.
Diving into the data
Estimated survival rates were 94% after 30 days, 81.4% after one year and 61.6% after three years. Perioperative mortality was 6% due to two deaths; one was from cardiogenic shock and the other was from bowel ischemia. The mean hospital length of stay was 10 days.
“This single-center analysis of a high-risk population that underwent TAVR explantation with subsequent SAVR demonstrates the highest short and mid-term survival of comparable cohorts published to date,” the authors wrote. “The incidence of TAVR explant among patients who underwent either index TAVR or valve-in-valve TAVR at our institution was 1.3%, similar to the reported incidence of TAVR-explant of 0.5-2%. Our study population mirrors other previously described TAVR-explant cohorts in terms of study period, mean age, STS-PROM score and rates of concomitant cardiac surgery.”
The group noted that “medical optimization,” “surgical expertise and efficiency” and “thoughtful postoperative management” all helped contribute to their positive patient outcomes. They also highlighted the importance of keeping surgeries simple whenever possible, “regardless of the extent of the procedure performed.” Patients who require concomitant mitral valve surgery in addition to TAVR explant, for example, have previously been linked to a reduced odds of survival following treatment.
“Patients that TAVR explant with or without concomitant surgery are high-risk by nature, yet the published rates of morbidity and mortality are excessive,” the group concluded. “As TAVR volumes continue to increase we, as a surgical community, are challenged to equate postoperative outcomes of TAVR explant with those of a redo aortic valve replacement. Understanding of our institutional-based cohorts is imperative to identify clinical subtilties that may bring about meaningful risk reduction to enable the feasibility, safety, and clinical success of this procedure and temporize the downstream effects of transcatheter heart valve failure.”
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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.