Minimally invasive removal of an infected Edwards S3 transcatheter aortic valve

Surgical Transcatheter Aortic Valve Replacement Explantation Technique

As TAVR (transcatheter aortic valve replacement) indications expand, cardiac surgeons need to be prepared to manage heretofore rare TAVR complications requiring explantation such as acute Type A dissection in these typically high-risk patients¹. Here we report successful use of an explantation technique which is hand ready-to-hand, efficient, and effective at avoiding further injury to the aortic root and coronary ostia.

Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications

OBJECTIVE

Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) and worldwide interest in its implantation, TAVR valve explantation has not been well described.

METHODS

We retrospectively reviewed 1442 consecutive patients who underwent a TAVR procedure between 2011 and 2019, in which TAVR explantation was performed in 15 patients (1.0%). In addition, 2 patients from outside institutions also underwent TAVR explantation at our institution. We reviewed the clinical details of these 17 patients.

RESULTS

The frequency of TAVR explant increased over time from 0 to 1 during the period from 2011 to 2015 to 6 in 2019. The mean age was 73.0 ± 9.3 years. The majority of patients (88.2%) were in New York Heart Association functional class IV heart failure. The Society of Thoracic Surgeons Predicted Risk of Mortality score was significantly higher at the time of explantation than at the time of the original TAVR (3.5% vs 9.9%; P < .001). The indication for explantation included structural valve degeneration (23.5%), severe paravalvular leak (41.2%), TAVR procedure-related complications (23.5%), endocarditis (5.9%), and bridge-to-definitive surgery (5.9%). Neoendothelialization of the TAVR valve into the aortic wall requiring intense aortic endarterectomy was noted in all 5 of the TAVR valves older than 1 year, in which 2 (40%) required unplanned aortic root repair. There were 2 (11.8%) in-hospital mortalities.

CONCLUSIONS

Surgical TAVR valve explant is increasing and may become common in the near future. The clinical effects of explanting chronically implanted valves with the potential need for aortic repair is not negligible. These data should be used to more appropriately select TAVR candidates as TAVR practices expand into younger and lower risk patients.