Challenging the transcatheter-first paradigm: Redo surgical aortic valve replacement after previous transcatheter or surgical aortic valve replacement.

Abstract

Aortic valve reoperations after transcatheter aortic valve replacement (TAVR) are increasing. However, concerns persist regarding poor clinical outcomes, whereas high cohort heterogeneity has historically precluded meaningful comparative analyses. We identified 1024 consecutive patients who underwent surgical aortic valve replacement (SAVR) after either TAVR (TAVR-SAVR; n = 127) or SAVR (SAVR-SAVR; n = 897) between 2011 and 2024. Among these, patients undergoing isolated SAVR ± coronary artery bypass grafting were included: 57 in the TAVR-SAVR group and 447 in the SAVR-SAVR group. The proportion of TAVR-SAVR among all aortic valve reoperations increased from 0% in 2011-2012 to 31.3% in 2024. Patients in the TAVR-SAVR group were older, exhibited greater comorbidity and heart failure burden, and had greater Society of Thoracic Surgeons Predicted Risk of Mortality. Despite 61.2% of TAVR-SAVR patients lacking previous sternotomy with shorter cardiopulmonary bypass and aortic crossclamp times, they demonstrated significantly greater operative mortality (12.3% vs 1.1%, P < .001). In contrast, the SAVR-SAVR cohort exhibited a remarkably low observed-to-expected mortality ratio of 0.33 (95% confidence interval, 0.11-0.76). After 1:2 propensity score matching (50 TAVR-SAVR vs 93 SAVR-SAVR patients), the TAVR-SAVR group continued to show greater operative mortality (12.0% vs 1.1%, P = .008) and greater composite complication rates. TAVR-SAVR cases are increasing and may surpass SAVR-SAVR cases by 2029. Despite matching, patients undergoing SAVR ± coronary artery bypass grafting showed worse outcomes in TAVR-SAVR, whereas a SAVR-SAVR strategy was extremely safe. Reconsideration of the TAVR-first strategy is warranted for patients expected to outlive the durability of TAVR prostheses.