Surgical Explantation of Transcatheter Aortic Valve Bioprostheses

Abstract

Background: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) since its initial approval in 2011, the frequency and outcomes of surgical explantation of TAVR devices (TAVR-explant) is poorly understood. Methods: Patients undergoing TAVR-explant between January 2012 and June 2020 at 33 hospitals in Michigan were identified in the Society of Thoracic Surgeons Database and linked to index TAVR data from the Transcatheter Valve Therapy Registry through a statewide quality collaborative. The primary outcome was operative mortality. Indications for TAVR-explant, contraindications to redo TAVR, operative data, and outcomes were collected from Society of Thoracic Surgeons and Transcatheter Valve Therapy databases. Baseline Society of Thoracic Surgeons Predicted Risk of Mortality was compared between index TAVR and TAVR-explant. Results: Twenty-four surgeons at 12 hospitals performed TAVR-explants in 46 patients (median age, 73). The frequency of TAVR-explant was 0.4%, and the number of explants increased annually. Median time to TAVR-explant was 139 days and among known device types explanted, most were self-expanding valves (29/41, 71%). Common indications for TAVR-explant were procedure-related failure (35%), paravalvular leak (28%), and need for other cardiac surgery (26%). Contraindications to redo TAVR included need for other cardiac surgery (28%), unsuitable noncoronary anatomy (13%), coronary obstruction (11%), and endocarditis (11%). Overall, 65% (30/46) of patients underwent concomitant procedures, including aortic repair/replacement in 33% (n=15), mitral surgery in 22% (n=10), and coronary artery bypass grafting in 16% (n=7). The median Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% at index TAVR and 9.3% at TAVR-explant ( P =0.001). Operative mortality was 20% (9/46) and 76% (35/46) of patients had in-hospital complications. Of patients alive at discharge, 37% (17/37) were discharged home and overall 3-month survival was 73±14%. Conclusions: TAVR-explant is rare but increasing, and its clinical impact is substantial. As the utilization of TAVR expands into younger and lower-risk patients, providers should consider the potential for future TAVR-explant during selection of an initial valve strategy.

Surgical explantation of transcatheter aortic bioprosthesis: A systematic review and meta-analysis

“…In addition, 75 articles were excluded for the following reasons: 35 studies that reported outcomes of SAVR explant, 32 studies that reported outcomes of valve-in-valve replacement, 5 case reports, 2 commentaries, and 1 study with significant duplicated data with other studies. 20 Ten articles met the inclusion and exclusion criteria and were included in the meta-analysis 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ( Figure E1 ). Most of the data variables from 2 of these articles 9 , 13 were excluded from the analysis owing to potential cohort duplication with other articles.…”

“… 16 The frequency of TAVR explants were reported in 4 articles. 10 , 11 , 14 , 15 Seven articles presented the age at TAVR explant 8 , 11 , 12 , 13 , 14 , 15 , 16 , 17 and 5 articles included the interval between index TAVR and TAVR explant. 8 , 9 , 11 , 12 , 14 STS-PROM at index TAVR was reported in 3 articles, 12 , 13 , 14 and STS-PROM at TAVR explant also was reported in 3 articles.…”

“… 10 , 11 , 14 , 15 Seven articles presented the age at TAVR explant 8 , 11 , 12 , 13 , 14 , 15 , 16 , 17 and 5 articles included the interval between index TAVR and TAVR explant. 8 , 9 , 11 , 12 , 14 STS-PROM at index TAVR was reported in 3 articles, 12 , 13 , 14 and STS-PROM at TAVR explant also was reported in 3 articles. 14 , 15 , 17 NYHA class at index TAVR was reported in 2 articles, 12 , 13 and that at TAVR explant was provided in 5 articles.…”

“… 8 , 9 , 11 , 12 , 14 STS-PROM at index TAVR was reported in 3 articles, 12 , 13 , 14 and STS-PROM at TAVR explant also was reported in 3 articles. 14 , 15 , 17 NYHA class at index TAVR was reported in 2 articles, 12 , 13 and that at TAVR explant was provided in 5 articles. 8 , 13 , 14 , 15 , 17 The type of explanted valve was reported in 6 articles.…”

“…Only a limited number of studies have described post-TAVR valve reinterventions, either repeat TAVR 6 , 7 or surgical TAVR valve explant (TAVR explant) procedures. 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 Of particular concern is the consistent dismal outcomes in patients requiring TAVR explant. In this context, we conducted a systematic review and meta-analysis to better characterize the clinical implications of TAVR explant in patients with a failing TAVR valve using existing evidence and ultimately help refine patient selection for TAVR as the initial valve procedure.…”