Early- and mid-term outcomes following redo surgical aortic valve replacement in patients with previous transcatheter aortic valve implantation

Abstract

Objectives To analyze the early and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI). Methods Retrospective single-center analysis of early and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival. Results During the study period a total of 5756 patients underwent TAVI. Amongst them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013–2016 and 2017–2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. Median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P < 0.001). Median elapsed time between TAVI and redo SAVR was 7 months (3.5 –14 months). Infective endocarditis (IE) was the most frequent indication for surgery [19 (67.8%) patients]. A total of 11 (39.3%) patients underwent isolated SAVR and 17 (60.7%) SAVR + additional cardiac surgical procedures. The overall in-hospital mortality was 14.3% (4/28). In-hospital mortality was 15.8% (3/19) among IE patients and 11.1% (1/9) among non-IE patients (p = 0.7). Overall estimated survival was 66.5%, 59.9% and 48.0% at 12, 18 and 24 months, respectively. Patients with IE showed a trend towards a lower estimated mid-term survival compared to non-IE patients [41.6% (95% CI; 22.0% - 78.0%) vs 58.3% (95% CI; 30.0% - 100%) survival at 24 months (p = 0.3)]. Conclusion SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

Operative management after transcatheter aortic valve replacement

“…The STS-PROM reported in the literature ranges from 4.8% to 11.6% (Table 1), with Yokoyama and colleagues reporting an average of 8.1% in their meta-analysis [9]. The median time between TAVR and operative management reported by Yokoyama and colleagues was 9.4 months [9], which is slightly longer than in our experience (7 months) [16]. The average time from TAVR to operative intervention reported in the literature ranges from 2.5 to 27.6 months (Table 1).…”

“…In our experience, these most commonly include aortic surgery (i.e. root repair and/or ascending aorta repair), mitral valve repair, and coronary artery bypass grafting (CABG) [16]. Yokoyama et al [9] also reported that aortic surgery was the most common concomitant procedure, followed by mitral valve repair/replacement and CABG.…”

“…Patients presenting for surgery after TAVR currently represent a high-risk group with mean age >70 years, frequent STS-PROM >8% and a history of previous cardiac operations with sternotomy (Table 1) [9]. The calculated risk is significantly higher at reoperation than at index TAVR [16], and more than 60% of patients present for surgery with New York Heart Association class III/IV heart failure [9]. The STS-PROM reported in the literature ranges from 4.8% to 11.6% (Table 1), with Yokoyama and colleagues reporting an average of 8.1% in their meta-analysis [9].…”

“…Surgery post-TAVR is frequently performed as a resternotomy procedure, with 14%-47% of patients having undergone previous cardiac operations, most commonly CABG [13,16,49]. The surgical approach must therefore account for the increased technical demands associated with resternotomy such as adhesions and risk of injury to mediastinal structures.…”

A 20-year journey in transcatheter aortic valve implantation: Evolution to current eminence

“…The largest so far observational analysis with 5,756 patients with previous TAVI, the incidence of redo SAVR after TAVI was 0.5% with the most frequent indication being infectious endocarditis (67.8% of patients). For most patients, 60.7% required additional cardiac surgical procedures and the overall 12-month mortality was 33.5% ( 42 ). On the other hand, ViV TAVI is associated with several considerations, including the risk of coronary obstruction, prosthesis-patient mismatch, and the need for previous surgical bioprosthesis cracking.…”