Surgical explantation of failed transcatheter heart valves: indications and results

Abstract

Given the recent surge in transcatheter heart valve replacement (THVR), cardiac surgeons will surely face the challenge of eventual explantation. The aim of this study was to determine indications for reoperation, while exploring pertinent technical aspects and survival after THV explantation in a cohort originally deemed high risk or even inoperable. Between February 2008 and March 2019, 31 patients with failed transcatheter aortic valve replacement (TAVR) underwent surgical explantations at our facility. Data were prospectively collected for retrospective analysis of procedural indications, technical issues, and postoperative survival. The major reason for TAVR removal was bioprosthetic valve failure (BVF) due to infective endocarditis (IE: 16/31 [51.6%]), non-structural (NSVD: 14/31 [45.2%]) and structural (SVD: 1/31 [3.2%]) valve deterioration accounting for the rest. Mean age at THV explantation was 76.3 ± 8.3 years, and median time from TAVR to explantation was 153 days (0 days–56.6 months). Median ICU and hospital stay were 6 days (1–44 days) and 23 days (8–62 days), respectively. Thirty-day and 1-year survival rates were 74.2% and 67.2%, respectively. Median follow-up interval after explantation was 364 days (3 days–80 months). Mean cardiopulmonary bypass time was 124.6 ± 46.8 min, and mean aortic cross-clamp time was 84.3 ± 32.9 min. There was no need for unplanned aortic root repair owing to tissue damage during dissection of the TAVR from surrounding tissue. The most common reason for THV explantation was (a) BVF for IE and (b) BVF secondary to NSVD. Although 30-day and 1-year mortality rates in this multimorbid cohort were predictably high, no procedural mortalities occurred.

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

“…After removal of duplicate entries, 459 articles were screened, of which 432 were excluded on the basis of titles and abstracts; a total of 26 relevant publications were retrieved for further assessment. Twelve studies [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ], analysing a total of 1584 participants receiving TAVR explant, met the inclusion criteria and were included in the quantitative analysis. A summary of the characteristics of the studies included is reported in Table 1 .…”

“… Summary of the main results from the systematic review. Forest plots tables for the outcomes of mortality, stroke, and renal failure, with metaregression plots below exploring the relationship between these outcomes and the ratio between self-expandable and balloon-expandable valves in the studies [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. CI—confidence interval .…”

“… Forest plots for secondary outcomes. Forest plots for the outcomes of 30-day readmission, new permanent pacemaker, and re-operation for bleeding [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. CI—confidence interval .…”

Operative management after transcatheter aortic valve replacement

“…Several studies have examined the incidence of surgical re-intervention post-TAVR. The overall incidence of operative interventions after TAVR was 0.4% in Michigan state as reported by Brescia et al [12], 1% in a report by Fukuhara et al from the University of Michigan [13], and 1.2% in a report by Muensterer et al from Munich [14]. Jawitz et al [15] in an analysis of the STS database estimated that the incidence of surgery after TAVR in the US is 0.3% nationwide.…”