Registry analyses have shown that transcatheter aortic valve replacement (TAVR) explantation carried the highest mortality risk for the rising number of patients needing aortic reintervention. The Society of Thoracic Surgeons (STS) data showed that the number of TAVR patients requiring a subsequent surgical valve (SAVR) grew significantly from 2011 to 2021. The number of patients with valve-in-valve TAVR followed by SAVR also increased, whereas the number of SAVR patients getting a second SAVR procedure remained stable.
Highest Operative Mortality in TAVR-SAVR Group
The STS data revealed that the highest operative mortality rate occurred in the TAVR-SAVR group, which was statistically significant compared to SAVR-SAVR. The operative mortality rate for TAVR-SAVR was 17%, while that for SAVR-SAVR was 9%. A similar result was observed in the EXPLANTORREDO-TAVR international registry, where TAVR followed by SAVR had higher mortality rates than SAVR-SAVR at 30 days and 1 year.
Call for Careful Assessment of Concurrent Cardiac Lesions
An editorial accompanying the two studies pointed out that clinicians have had little evidence to rely on for the treatment of bioprosthetic failure. The editorialists acknowledged the need for developing more accurate prediction models for life expectancy to determine patients who will outlive the durability of a TAVR prosthesis prospectively. They also offered an algorithm for choice on first procedures, which includes careful assessment of concurrent cardiac lesions and future TAVR repeatability during the initial valve selection process.
Limitations of both studies included the lack of data on mechanism of structural valve deterioration, retrospective design, and potential selection bias. However, the studies added an important piece of the puzzle and highlighted the importance of filling the missing piece of information about the mid- and long-term performance of redo TAVR compared with TAVR-in-SAVR. If these two reinterventions have comparable outcomes, TAVR repeatability might be as important as THV durability.
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