Surgical Explantation of Failed Transcatheter Aortic Valve Replacement

Syed Zaid; Sameer A Hirji; Vinayak N Bapat; Paolo Denti; Thomas Modine; Tom C Nguyen; Michael J Mack; Michael J Reardon; Tsuyoshi Kaneko; Gilbert H L Tang; EXPLANT-TAVR Investigators

doi:10.1016/j.athoracsur.2023.05.036

Surgical Explantation of Failed Transcatheter Aortic Valve Replacement

Ann Thorac Surg. 2023 Nov;116(5):933-942. doi: 10.1016/j.athoracsur.2023.05.036. Epub 2023 Jun 22.

Authors

Collaborators

EXPLANT-TAVR Investigators:
Shekhar Saha¹¹, Philipp Kiefer¹², David Holzhey¹², Thilo Noack¹², Pierre Voisine¹³, Siamak Mohammadi¹³, Katherine B Harrington¹⁴, John J Squiers¹⁴, Shinichi Fukuhara¹⁵, Moritz Wyler von Ballmoos¹⁶, Sachin S Goel¹⁷, Marvin D Atkins¹⁷, Oliver D Bhadra¹⁸, Lenard Conradi¹⁸, Christian Shults¹⁹, Lowell F Satler¹⁹, Luigi Pirelli²⁰, Derek R Brinster²⁰, Muhanad Algadheeb²¹, Michael W A Chu²¹, Rodrigo Bagur²¹, Basel Ramlawi²², Kendra J Grubb²³, Nimesh D Desai²⁴, Newell B Robinson²⁵, Lin Wang²⁵, George A Petrossian²⁵, Lionel Leroux²⁶, John R Doty²⁷, Joerg Kempfert²⁸, Axel Unbehaun²⁸, Hussein Rahim²⁹, Arnar Geirsson³⁰, John K Forrest³⁰, Flavien Vincent³¹, Eric Van Belle³¹, Mohamad Koussa³¹, Joshua B Goldberg³², Hasan A Ahmad³², Walid Ben Ali³³, Philippe Demers³³, Reda Ibrahim³³, Martin Andreas³⁴, Paul Werner³⁴, Kashish Goel³⁵, Ashish S Shah³⁵, Guido Gelpi³⁶, Marc Ruel³⁷, Talal Al-Atassi³⁷, Nicholas M Van Mieghem³⁸, Thijmen W Hokken³⁸, Augusto D'Onofrio³⁹, Chiara Tessari³⁹, Pinak B Shah⁴⁰, Igor Belluschi⁴¹, Andrea Garatti⁴², Giuseppe Bruschi⁴³, Maral Ouzounian⁴⁴, Alejandro Pizano⁴⁵, Marco Di Eusanio⁴⁶, Filippo Capestro⁴⁶, Joshua Rovin⁴⁷, Maurizio Taramasso⁴⁸, Marco Gennari⁴⁰, Andrea Colli⁴⁹, Rodrigo Estevez-Loureiro⁵⁰, Miguel A Pinon⁵⁰, Michael H Salinger⁵¹, Antonio Di Virgilio⁵², Brian K Whisenant²⁷, Tamim M Nazif²⁹, Neal S Kleiman¹⁷, Molly I Szerlip¹⁴, Ron Waksman¹⁹, Josep Rodés-Cabau¹³, Isaac George²⁹, J Michael DiMaio¹⁴, Francesco Maisano⁴¹, G Michael Deeb¹⁵, Keti Vitanova⁵³, Rudiger Lange⁵³, Michael A Borger¹², Christian Hagl¹¹, Joseph E Bavaria²⁴

Affiliations

¹ Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
² Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts.
³ Division of Cardiothoracic Surgery, Abbott Northwestern Hospital, Minneapolis, Minnesota.
⁴ Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy.
⁵ Department of Cardiovascular Surgery, CHU Bordeaux, Bordeaux, France.
⁶ Division of Cardiothoracic Surgery, University of California San Francisco Medical Center, San Francisco, California.
⁷ Division of Cardiothoracic Surgery, Baylor Scott and White Health Heart Hospital, Plano, Texas.
⁸ Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
⁹ Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
¹⁰ Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York. Electronic address: gilbert.tang@mountsinai.org.
¹¹ LMU Klinikum Munich, Munich, Germany.
¹² Leipzig Heart Center, Leipzig, Germany.
¹³ Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
¹⁴ Baylor, Scott & White The Heart Hospital, Plano, Texas.
¹⁵ University of Michigan, Ann Arbor, Michigan.
¹⁶ University Hospital Zurich, Zurich, Switzerland.
¹⁷ Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas.
¹⁸ University Heart and Vascular Center Hamburg, Hamburg, Germany.
¹⁹ MedStar Washington Hospital Center, Washington, DC.
²⁰ Lenox Hill Hospital, Northwell Health, New York, New York.
²¹ London Health Sciences Center, Western University, London, Ontario, Canada.
²² Lankenau Heart Institute, Philadelphia, Pennsylvania.
²³ Emory University, Atlanta, Georgia.
²⁴ University of Pennsylvania, Philadelphia, Pennsylvania.
²⁵ St Francis Hospital, Roslyn, New York.
²⁶ CHU Bordeaux, Bordeaux, France.
²⁷ Intermountain Health, Salt Lake City, Utah.
²⁸ German Heart Center Berlin, Berlin, Germany.
²⁹ Columbia University Irving Medical Center, New York, New York.
³⁰ Yale School of Medicine, New Haven, Connecticut.
³¹ CHU Lille, University of Lille, Lille, France.
³² Westchester Medical Center, Valhalla, New York.
³³ Montreal Heart Institute, Montreal, Quebec, Canada.
³⁴ Medical University of Vienna, Vienna, Austria.
³⁵ Vanderbilt University, Nashville, Tennessee.
³⁶ Sacco Hospital, ASST-Fatebenefratelli-Sacco, University of Milan, Milan, Italy.
³⁷ University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
³⁸ Erasmus University Medical Center, Rotterdam, The Netherlands.
³⁹ University of Padova, Padova, Italy.
⁴⁰ Brigham & Women's Hospital, Boston, Massachusetts.
⁴¹ San Raffaele University Hospital, Milan, Italy.
⁴² IRCCS Policlinico San Donato, Milan, Italy.
⁴³ ASST Niguarda General Hospital, Milan, Italy.
⁴⁴ University Health Network, Toronto, Toronto, Ontario, Canada.
⁴⁵ University of Texas Health Science Center at Houston, Houston, Texas.
⁴⁶ Lancisi Cardiovascular Center, OORR, Politechnic University of Marche, Ancona, Italy.
⁴⁷ Morton Plant Hospital, Clearwater, Florida.
⁴⁸ HerzZentrum Hirslanden, Zurich, Switzerland; (39)IRCCS Centro Cardiologico Monzino, Milan, Italy.
⁴⁹ University of Pisa, Pisa, Italy.
⁵⁰ University Hospital Alvaro Cunqueiro, Vigo, Spain.
⁵¹ Medical College of Wisconsin, Milwaukee, WisconsinA.
⁵² Mater Domini University Hospital, Catanzaro, Italy.
⁵³ German Heart Center Munich, Munich, Germany.

PMID: 37354965
DOI: 10.1016/j.athoracsur.2023.05.036

Abstract

Background: Recent reports have demonstrated worse than expected outcomes of surgical explantation after transcatheter aortic valve replacement (TAVR). However in-depth analysis of the short- and mid-term risk of concomitant cardiac surgery at the time of TAVR explant is lacking.

Methods: Data from the multicenter EXPLANT-TAVR registry of patients undergoing TAVR-explant between November 2009 and September 2020 were retrospectively analyzed. Patients undergoing concomitant procedures were included, but explants performed during the same admission as the initial TAVR or concomitant procedures performed on the aortic root, ascending aorta, or arch were excluded. Outcomes were evaluated between the isolated surgical aortic valve replacement (SAVR) and concomitant SAVR groups. Median follow-up was 6.6 months.

Results: Among 199 patients, concomitant SAVR was performed in 94 patients (47.2%), primarily with mitral valve surgery (n = 45) followed by coronary artery bypass grafting (n = 23). Despite similar mean ages between groups (72.8 vs 73.4 years), concomitant SAVR had a higher median Society of Thoracic Surgeons Predicted Risk of Mortality score at the index TAVR (5.9% vs 3.7%, P = .001). There were no differences in median time-to-explant between groups (12.9 vs 8.7 months, P = .78). However concomitant SAVR had longer mean cardiopulmonary bypass (166 vs 114 minutes, P = .001) and cross-clamp times (123 vs 81 minutes, P = .001). Both 30-day (16.7% vs 9.9%) and 1-year mortality (36.1% vs 22.1%) were higher with concomitant SAVR but did not reach statistical significance (both P > .05). On Kaplan-Meier analysis, actuarial estimates of cumulative survival were significantly lower with concomitant SAVR at 3 years (56.8% vs 81.1%, P = .020).

Conclusions: For surgical explantation after TAVR failure, concomitant SAVR is associated with increased mortality. Further studies with longer follow-up are warranted to examine the benefit from earlier intervention before concomitant disease develops.