Surgical explantation of failed transcatheter heart valves: indications and results

The current state of transcatheter aortic valve replacement explant: an updated systematic review

Background

Despite ever-growing adoption of transcatheter aortic valve replacement (TAVR) in younger healthier patients, a limited number of studies have described post-TAVR valve reinterventions such as surgical explantation known as "TAVR explant".

Methods

We performed a systematic review to characterize the current state of TAVR explant in patients with a failing transcatheter heart valve (THV) using data published by April 30, 2024 in compliance with the PRISMA and MOOSE reporting guidelines. The protocol was registered in PROSPERO (CRD42024529188).

Results

Twenty-eight studies met the eligibility criteria. Almost all studies were non-randomized, observational, and retrospective. The incidence of TAVR explant ranged from 0.2% to 2.8% in patients with a mean age of 67.3-79.0 years, and women representing 25.0-47.1% of cases. The mean time between TAVR implant and explant was 17.0-674.9 days, with most studies reporting a mean time <365 days. Whereas the Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score at the time of the TAVR implant ranged between 2.6% and 7.7% (with only one study with score >5%), the STS-PROM score at the time of the TAVR explant ranged between 3.9% and 9.9% (with 17 studies with score >5%). Isolated surgical aortic valve replacement (SAVR) happened in 16.2-100% of cases, aortic root replacement was required in 2.6-41.2%, ascending aortic replacement was performed in 3.2-33.3% of cases. Mitral valve repair/replacement was necessary in 11.8-43.5% and tricuspid valve/repair replacement was done in 2.8-25.0%. Stroke rates were between 0.0% and 20.0% with most studies with rates above 4.0%. The 30-day death rate ranged from 4.8% to 50.0% with most studies with mortality rates higher than 10%. Observed-to-expected mortality ratio was higher than 1.0 in almost all the studies that reported this variable.

Conclusions

TAVR explant remains a rare event, but its clinical impact is non-negligible. Lifetime management strategies should be adopted in younger lower-risk patients when choosing THVs for the index TAVR.

Valve Type and Operative Risks in Surgical Explantation of Transcatheter Aortic Valves: A Systematic Review and Meta-Analysis

Indication to perform surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of transcatheter procedures performed in patients with longer life expectancy. We proposed to perform a systematic review and meta-analysis with metaregression to identify potential factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. TAVR explantation was confirmed as a procedure with high 30-day mortality (0.17; 95% CI, 0.14-0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04-0.07; kidney injury incidence 16%; 95% CI, 0.11-0.24). The type of transcatheter valve implanted during the index procedure did not influence the outcomes after surgical explantation. The role of these high-risk operations is growing, and it will likely expand in the coming years. Specific tools for risk stratification are required.

TAVR in TAVR: Where Are We in 2023 for Management of Failed TAVR Valves?

PURPOSE OF REVIEW

As TAVR is increasingly performed on younger patients with a longer life expectancy, the number of redo-TAVR procedures is likely to increase in the coming years. Limited data is currently available on this sometimes challenging procedure. We provide a summary of currently published literature on management of patients with a failed transcatheter aortic valve.

RECENT FINDINGS

Recent registry data have increased the clinical knowledge on redo-TAVR. Additionally, numerous bench studies have provided valuable insights into the technical aspects of redo-TAVR with various combinations of valve types. Redo-TAVR can be performed safely in selected cases with a high procedural success and good short-term outcomes. However, at present, the procedure remains relatively infrequent and many patients are not eligible. Bench testing can be useful to understand important concepts such as valve expansion, neoskirt, leaflet overhang, and leaflet deflection as well as their potential clinical implications.