• Analysis: Surgical Explant of THVs After TAVR Brings Higher Risk vs. Redo SAVR

    BOSTON — Surgical explantation of transcatheter heart valves (THVs) after transcatheter aortic valve replacement (TAVR) confers a higher risk of mortality and other clinical outcomes compared with redo surgical aortic valve replacement (SAVR), a new analysis shows.

    Robert B. Hawkins, MD, MSc, of the University of Michigan, presented these findings Sunday at Transcatheter Cardiovascular Therapeutics (TCT) 2022 in Boston.

    Young patients with aortic stenosis need to have a plan for multiple valves. The plan involves the patient’s age, annular and root anatomy, preference, and unknown additional risks associated with valve-in-valve TAVR and THV explant, Hawkins said.

    The current study, therefore, set out to clarify the risks of THV explant relative to redo SAVR, specifically comparing patients who first undergo SAVR and then a ViV TAVR and those who first undergo TAVR and then undergo surgery as compared to redo SAVR. It analyzed the Society of Thoracic Surgeons Participant User File database for aortic valve replacement cases from 2011 to 2021, excluding non-bioprosthetic valves and non-aortic valve pathology. It included a sub-analysis of isolated aortic valve cases, with regression and propensity-score matching for risk adjustment.

    The volume of redo SAVR  has leveled off at about 3,500 per year since 2016, but redo SAVR still represents the vast majority of reoperative AVR, Hawkins said, while cases of reoperative AVR after TAVR and after prior SAVR + TAVR have accelerated from just a handful in 2014 to more than 200 in 2021.

    The TAVR-then-SAVR patients were, as expected, older (74 years vs. 67 years), with greater comorbid disease and more percutaneous coronary intervention (PCI: 30% vs. 12%) compared to SAVR-then-SAVR patients, Hawkins said. The SAVR-TAVR-SAVR cohort fell roughly in the middle between those two groups, he said.

    Accordingly, operative mortality was 17% (195/1,126) in the TAVR-SAVR group, 12% (81/674) in the SAVR-TAVR-SAVR group and 9% (2,548/29,306) in the SAVR-SAVR group (p<0.001).

    Risk-adjusted outcomes showed that TAVR-SAVR patients had a higher mortality odds ratio (OR), about 1.5, than the SAVR-SAVR group, whereas the SAVR-TAVR-SAVR group appears to have about the same odds of mortality as the SAVR-SAVR group, Hawkins said.

    When the investigators matched isolated aortic valve cases in each cohort, it still showed an increased odds of mortality in the TAVR-SAVR group (11.3%) compared to the SAVR-SAVR group (6.7%), despite shorter operative times in the TAVR-SAVR group. Hawkins also noted a higher “failure to rescue” rate in the TAVR-SAVR group (32% vs. SAVR-SAVR 16%), along with higher renal failure (9% vs. 5%) and longer intensive care unit stay (74 hours vs. 68 hours).

    “TAVR explant remains a low-volume operation with increased risk when compared with redo SAVR cases,” Hawkins said. “Consideration should be given to centralizing these cases at high-volume centers of excellence and needs further study.”

    He added that this increased future risk of TAVR “needs to be disclosed to patients and accounted for in plans for lifetime management of aortic stenosis.”

    Image Credit: Jason Wermers/CRTonline.org

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