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. 2021 Aug;162(2):539-547.e1.
doi: 10.1016/j.jtcvs.2019.11.139. Epub 2020 Jan 12.

Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications

Shinichi Fukuhara  1 , Alexander A Brescia  2 , Suzuna Shiomi  2 , Carlo M Rosati  2 , Bo Yang  2 , Karen M Kim  2 , G Michael Deeb  2
Affiliations

Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications

Shinichi Fukuhara et al. J Thorac Cardiovasc Surg. 2021 Aug.

Abstract

Objective: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) and worldwide interest in its implantation, TAVR valve explantation has not been well described.

Methods: We retrospectively reviewed 1442 consecutive patients who underwent a TAVR procedure between 2011 and 2019, in which TAVR explantation was performed in 15 patients (1.0%). In addition, 2 patients from outside institutions also underwent TAVR explantation at our institution. We reviewed the clinical details of these 17 patients.

Results: The frequency of TAVR explant increased over time from 0 to 1 during the period from 2011 to 2015 to 6 in 2019. The mean age was 73.0 ± 9.3 years. The majority of patients (88.2%) were in New York Heart Association functional class IV heart failure. The Society of Thoracic Surgeons Predicted Risk of Mortality score was significantly higher at the time of explantation than at the time of the original TAVR (3.5% vs 9.9%; P < .001). The indication for explantation included structural valve degeneration (23.5%), severe paravalvular leak (41.2%), TAVR procedure-related complications (23.5%), endocarditis (5.9%), and bridge-to-definitive surgery (5.9%). Neoendothelialization of the TAVR valve into the aortic wall requiring intense aortic endarterectomy was noted in all 5 of the TAVR valves older than 1 year, in which 2 (40%) required unplanned aortic root repair. There were 2 (11.8%) in-hospital mortalities.

Conclusions: Surgical TAVR valve explant is increasing and may become common in the near future. The clinical effects of explanting chronically implanted valves with the potential need for aortic repair is not negligible. These data should be used to more appropriately select TAVR candidates as TAVR practices expand into younger and lower risk patients.

Keywords: aortic endarterectomy; aortic root replacement; structural valve degeneration; surgical aortic valve replacement; transcatheter aortic valve replacement.

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Conflict of interest statement

Conflict of Interest Statement: S.F. serves as a consultant for Terumo Aortic. A.A.B. is supported by the National Research Service Award postdoctoral fellowship (No. 5T32HL076123). B.Y. is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health and Phil Jenkins and Darlene & Stephen J. Szatmari Funds. Others have no relevant disclosures.

Figures

Figure 1.
Figure 1.
Intraoperative photographs of a 6.5-year-old CoreValve device explant. (A) The distal edge of the stent cage seen through the flaccid aorta (arrow). (B) Aortotomy made 1 cm distal to the stent cage with severely endothelialized transcatheter valve into the aorta (arrow). (C) Disintegrated aortic wall after aortic endarterectomy for the device removal. (D) Explanted device with structural valve degeneration and denuded aortic intima remnants attached to the stent cage.
Figure 2.
Figure 2.
Intraoperative photographs of a 5.3-year-old Sapien device explant. (A) Severely calcified and endothelialized device with its stent cage barely visible. There were numerous calcifications and cholesterol deposits including the area adjacent to the coronary ostia. (B) Kocher clamp maneuver to facilitate liberation of the transcatheter valve. (C) Disintegrated aortic root after aortic endarterectomy and device removal. (D) Partial aortic root replacement of the non-coronary sinus segment with patch repair of the supra-coronary aorta.
Figure 3.
Figure 3.
Trend of surgical transcatheter aortic prosthesis explant procedure case number by year. TAVR, transcatheter aortic valve replacment
Figure 4.
Figure 4.
Box plots of the Society of Thoracic Surgeons Predicted Risk of Mortality at time of index transcatheter aortic valve replacement and surgical transcatheter valve removal with/without incremental risk factors. STS-PROM, The Society of Thoracic Surgeons Predicted Risk of Mortality
Central Picture
Central Picture
A 5.3-year-old balloon expandable device and post-device explant disintegrated aorta.
See this image and copyright information in PMC

Comment in

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