Long-Term Outcomes of Repeated Transcatheter Aortic Valve Replacement vs Transcatheter Aortic Valve Replacement Explantation: A Nationwide Analysis.

Abstract

Comparative durability of subsequent procedures after transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to assess long-term outcomes of repeated TAVR vs TAVR explantation for bioprosthetic valve dysfunction after TAVR. Medicare beneficiaries undergoing aortic valve reintervention after index TAVR (January 2012-December 2020) were assigned to repeated TAVR or TAVR explantation categories. Exclusion criteria included endocarditis or reintervention during the same admission. Primary outcome was 5-year mortality; secondary outcomes included major adverse cardiovascular events (death, pacemaker placement, major bleeding, stroke, acute kidney injury, cardiac arrest). Time-to-event analyses used Kaplan-Meier curves. Adjusted outcomes were assessed by 1:1 propensity matching. Of 1172 patients undergoing reintervention after TAVR, 70.6% had repeated TAVR and 29.4% had TAVR explantation. Repeated TAVR patients were older and more often female, with higher Charlson comorbidity score (all P < .05). Median follow-up was 29.2 months (27.7 months repeated TAVR, 32.3 months TAVR explantation). In the propensity score-matched cohorts, 30- and 90-day mortality was higher after TAVR explantation, but Kaplan-Meier estimated cumulative mortality was lower in TAVR explantation at 3 and 5 years (all P < .001). Survival curves crossed at approximately 9 months, after which TAVR explantation maintained a persistent advantage. The hazard ratio during the entire follow-up was 0.61 (95% CI, 0.49-0.75; P < .001). Similar survival patterns were observed across Charlson comorbidity stratification and after exclusion of concomitant procedures. Although repeated TAVR showed lower short-term mortality, long-term outcomes favored TAVR explantation. These findings suggest that for Medicare beneficiaries experiencing TAVR failure, there is a subset of patients who could benefit from TAVR explantation over repeated TAVR.