Decision-making in valve reintervention: Redo-Transcatheter aortic valve replacement vs. explant surgery.

Abstract

Objective: Data remain limited on factors influencing the selection of redo-transcatheter aortic valve replacement (TAVR) versus surgical explant in patients with failing transcatheter heart valves. This study aimed to identify clinical and procedural factors guiding treatment decisions.

Methods: This single-center, retrospective study included all patients who underwent aortic valve reintervention following prior TAVR at a U.S. tertiary referral center between January 2015 and June 2024. Clinical records, imaging, and Heart Team notes were reviewed to determine rationale for treatment selection. Procedural details and major adverse cardiac events (MACE: death, rehospitalization, or stroke) were collected.

Results: Among 47 patients, 24 (51 %) underwent surgical explant and 23 (49 %) redo-TAVR. The explant group was significantly younger (75 vs. 79 years; p = 0.018), with similar gender distribution (31.9 % female). Time to reintervention was comparable (27.8 vs. 34.2 months; p = 0.75). Common indications for explant included endocarditis (33.3 %), patient-prosthesis mismatch (16.7 %), prior valve-in-valve (16.7 %), annular rupture risk (12.5 %), need for concomitant surgery (8.3 %), and coronary obstruction risk (8.3 %). Thirty-day and one-year MACE rates were significantly higher with explant (30.4 % vs. 0 %, p = 0.029; 59.1 % vs. 21.4 %, p = 0.041). Mortality was numerically higher but not statistically significant. Patients undergoing explant often had more comorbidities and required complex procedures.

Conclusion: Among patients undergoing reintervention after TAVR, treatment was evenly split between redo-TAVR and explant, underscoring the importance of lifetime planning at initial TAVR. This analysis shows the two groups represent inherently different patient populations and highlights the need for randomized trials to define optimal treatment pathways.