Trends in aortic valve reintervention: Incidence and outcomes after failed transcatheter aortic valve implantation among patients receiving Medicare.

Abstract

With the growing use of transcatheter aortic valve implantation (TAVI), data on TAVI failure and outcomes after reintervention remain limited. This study describes trends in reinterventions and associated outcomes, including mortality and heart failure hospitalization in elderly patients. Using the Medicare database, we identified 324,701 patients who underwent TAVI during 2013-2022. Trends in aortic valve reinterventions-including TAVI-in-TAVI and surgical explants-were analyzed using Joinpoint regression to report annual percent change (APC). A Cox proportional hazards model was used to estimate the association between the year of reintervention and the risk of outcomes as hazard ratios. Between 2013 and 2022, 2387 patients underwent aortic valve reintervention after TAVI (61.3% TAVI-in-TAVI and 38.7% surgical aortic valve replacement). The number of aortic valve reinterventions increased from 49 in 2013 to 505 in 2022 (APC: 22.1%; P < .001). There was an initial decline in the TAVI-in-TAVI incidence rate per 1000 person-years (APC: -27.6% from 2013 to 2019), followed by a significant increase (APC: 35.2% from 2019 to 2022). Meanwhile, the incidence rate remained unchanged for explant until 2017, after which it increased (APC: 18.3%; P < .001). After reintervention, 8.7% of patients died within 30 days, and 18.7% within 1 year. The adjusted risk of mortality (hazard ratio, 0.96; 95% CI, 0.93-0.99; P = .01) and heart failure hospitalization (subdistribution hazard ratio, 0.87; 95% CI, 0.83-0.91; P < .001) declined significantly over time. Reinterventions, mainly surgical explants, have increased after TAVI. However, associated mortality and heart failure hospitalization have declined, reflecting an improvement in the management of failed TAVI in elderly patients. Further research into rising explant rates is warranted.