Explantation of Transcatheter Aortic Bioprostheses in a Very High Risk Population.

Abstract

Transcatheter aortic valve replacement explantation is associated with excessive rates of mortality. We describe a high-risk cohort of patients who underwent surgical explantation with excellent outcomes at our institution. This is a single-center, retrospective analysis of all patients who underwent surgical removal of a transcatheter bioprosthesis between January 2015 and April 2023. Clinical and operative characteristics were reviewed by direct chart review, and survival was estimated. Thirty-three patients underwent device explantation. Mean age was 75 ± 5.9 years. The Society of Thoracic Surgeons predicted risk of mortality score was 7.34 at surgical explantation. Eighteen patients (55%) had previous cardiac surgery, with 15 secondary and 3 tertiary sternotomies. Fourteen patients had prior valve-in-valve transcatheter aortic valve replacement (TAVR). Indications for explantation were prosthetic valve degeneration (46%), endocarditis (33%), paravalvular leak (15%), and ventricular septal defect (6%). Median TAVR valve age was 815 days. Twenty-two patients required a concomitant operation including mitral valve replacement (21%), aortic operation (9%), coronary bypass grafting (18%), myectomy (6%), and atrial or ventricular septal defect repair (12%). None required aortic root replacement. Mean hospital length of stay was 10 ± 8 days. Postoperative complications included new renal failure (6%), respiratory failure (15%), pacemaker implantation (3%), and reentry for bleeding (3%). No patient suffered a stroke. Thirty-day, 1-year, and 3-year mortality rates were 6%, 18.6%, and 38.4%. Our study demonstrates that acceptable outcomes are attainable in a high-risk patient cohort undergoing TAVR explantation. It is imperative to identify modifiable risk factors to achieve consistent outcomes as TAVR and device explantation continue to rise.