When heart patients undergo surgical aortic valve replacement (SAVR) after transcatheter aortic valve replacement (TAVR)—or they unexpectedly need to be switched from TAVR to SAVR in the middle of the procedure—there may be a high risk of in-hospital mortality.
That was the finding of a new single-center analysis published in the American Journal of Cardiology.[1]
“The evolution of TAVR has revolutionized the treatment of aortic stenosis,” wrote lead author Takuya Ogami, MD, of the department of cardiothoracic surgery at the University of Pittsburgh Medical Center, and colleagues. “However, questions continue to remain regarding the long-term durability of the TAVR. The need for future cardiac surgery is an important consideration. Although structural valve degeneration is only one reason to consider reoperative cardiac surgery, other factors—such as infective endocarditis (IE), secondary valve disease, and complex coronary disease—may be factors to consider when evaluating patients for cardiac surgery.”
Ogami et al. examined data from 2,100 patients who underwent TAVR at the same academic facility from 2013 to 2021. Just 0.8% of those patients—17 in total—went on to undergo SAVR after TAVR or during TAVR. The mean patient age was 78.3 years old. The median duration from TAVR to SAVR was 2.3 months.
At the time of the original TAVR procedure, the mean Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) was 7.7%.
Surgical bailout—which, the authors explained, is required when “an irreparable complication occurs during the TAVR procedure, such as annular rupture or coronary obstruction or a type A aortic dissection”—was needed for eight patients, making it the most common reason for SAVR after TAVR among this patient population. A dislodged heart valves, aortic valve annular rupture and prosthesis-patient mismatch were the three reasons surgical bailout was needed.
IE and paravalvular leak were the other most common reasons for SAVR after TAVR, and one patient underwent explant TAVR “to enable mitral valve surgery.” Valve-in-valve TAVR was viewed as a valid treatment option for these specific patients.
The STS-PROM at the time of surgery was 11.5%—a noted increase from the mean score at the time of the initial TAVR procedure.
Diving deeper into the patient data, Ogami and colleagues reported that 13 patients were treated “urgently or emergently.” While seven patients required an aortic root replacement, two required aortic root enlargement and one required an aortic root endarterectomy. Patch reconstruction was needed for five patients.
In-hospital mortality for this small group of patients was 41.2%. Mortality after one year was 53%. Patients were followed for up to 23.6 months. One patient had a stroke while hospitalized, but no other patients had a stroke during follow-up.
The authors did recognize that the mortality seen in this analysis was higher than it was in some other recent studies, a difference they said could be because aortic root reconstruction was necessary for so many patients who underwent SAVR after TAVR. IE was also a more common reason for heart valve explant in this study (44.4%) than some of the other previous studies. The group also noted that their work had certain limitations, including the small sample size and the fact that all data came from a single facility.
Even with these differences and limitations in mind, however, the team’s work helped provide new context about a subject that will only grow in importance as TAVR becomes more and more common.
“The frequency of transcatheter heart valve explantation remains low,” the authors concluded. “These data will continue to be highly relevant as we look to the future in patients who will need reoperative surgery after TAVR for endocarditis, patient prosthesis mismatch, or when valve-in-valve TAVR is not feasible.”
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.