Surgical explantation of transcatheter aortic bioprosthesis: A systematic review and meta-analysis

Abstract

Background: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), aortic valve reintervention, particularly surgical TAVR valve explantation (TAVR explant), has not been well described.

Methods: MEDLINE, Embase, and Web of Science were searched through July 2021 to identify observational studies and case series reporting clinical outcomes of TAVR explant. Data on the frequency of TAVR explant, patient demographic characteristics, clinical indications, operative data, and perioperative outcomes were extracted. Study-specific estimates were combined using one-group meta-analysis in a random-effects model.

Results: A total of 10 studies were identified that included 1690 patients undergoing a TAVR explant. The frequency of TAVR explant among TAVR recipients was 0.4% (95% confidence interval [CI], 0.2%-0.6%). The mean patient age was 73.7 years (95% CI, 72.9-74.6 years). The mean Society of Thoracic Surgeons predicted risk of mortality was 5.9% (95% CI, 2.9%-8.8%) at the index TAVR and 8.1% (95% CI, 5.4%-10.8%) at TAVR explant. The mean time from implant to explant was 345.0 days (95% CI, 196.7-493.3 days). Among patients with documented device type, 59.8% (95% CI, 43.5%-76.0%) had a balloon-expandable valve and 40.2% (95% CI, 24.0%-56.5%) had a self-expandable valve. Concomitant procedures during TAVR explant were performed in 52.9% of patients (95% CI, 33.8%-72.0%), and the most common concomitant procedure was aortic repair (28.5%; 95% CI, 14.0%-42.9%). The 30-day mortality after TAVR explant was 16.7% (95% CI, 12.2%-21.2%).

Conclusions: TAVR explant in patients with a failing TAVR appears to be rare; however, the clinical impact of TAVR explant is substantial. Implanters must be mindful of the need for a lifetime management strategy in younger and lower-risk patients when choosing the valve type for the initial procedure.

Keywords: CI, confidence interval; NYHA, New York Heart Association; SAVR, surgical aortic valve replacement; STS-PROM, Society of Thoracic Surgeons predicted risk of mortality; TAVR, transcatheter aortic valve replacement; reoperative cardiac surgery; structural valve degeneration; surgical aortic valve replacement; surgical transcatheter aortic bioprosthesis explantation; transcatheter aortic valve replacement.

Graphical abstract

Intraoperative photographs of surgical transcatheter aortic bioprosthesis explantation.

Figure 1

Forest plots of the included studies showing the pooled estimate of the frequency of transcatheter aortic valve explantations. CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure 2

Forest plots of the included studies showing the pooled estimate of the mean Society of Thoracic Surgery predicted risk of mortality (STS-PROM) score at the time of transcatheter aortic bioprosthesis implant (A) and explant (B). CI, Confidence interval.

Figure 3

Forest plots of the included studies showing the pooled estimate of the mean time interval (days) from transcatheter aortic bioprosthesis implant to explant. CI, Confidence interval.

Figure 4

Forest plots of the included studies showing the pooled estimate of 30-day mortality after surgical transcatheter aortic bioprosthesis explantation. CI, Confidence interval; EV, number of even; TRT, number of treated.

Figure 5

Meta-analysis of 10 studies including 1690 patients who underwent surgical explantation of transcatheter aortic bioprosthesis. TAVR, Transcatheter aortic valve replacement; TAVR explant, surgical explantation of transcatheter aortic bioprosthesis.

Figure E1

PRISMA flow chart.

Figure E2

Forest plots of the included studies showing the pooled estimate of the age at transcatheter aortic valve explantation. CI, Confidence interval.

Figure E3

Forest plots of the included studies showing the pooled estimate of the proportion of previous cardiac surgery. CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E4

Forest plots of the included studies showing the pooled estimate of the proportion of explanted device type: balloon-expandable valves (A) and self-expandable valves (B). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E5

Forest plots of the included studies showing the pooled estimates of the proportion of indications for transcatheter valve explantation: endocarditis (A), structured valve degeneration (B), paravalvular leak/aortic insufficiency (C), failed implantation (D), aortic stenosis (E), and others (F). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E5

Forest plots of the included studies showing the pooled estimates of the proportion of indications for transcatheter valve explantation: endocarditis (A), structured valve degeneration (B), paravalvular leak/aortic insufficiency (C), failed implantation (D), aortic stenosis (E), and others (F). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E6

Forest plots of the included studies showing the pooled estimate of the proportions of isolated procedures (A) and concomitant procedures (B). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E7

Forest plots of the included studies showing the pooled estimate of the proportions of concomitant procedures at the time of TAVR explant: aortic repair (A), aortic root repair (B), and ascending aortic repair (C). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E8

Forest plots of the included studies showing the pooled estimate of the proportion of concomitant mitral valve repair/replacement at the time of TAVR explant. CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E9

Forest plots of the included studies showing the pooled estimate of the proportion of concomitant procedures at the time of TAVR explant: coronary artery bypass grafting (A) and tricuspid repair/replacement (B). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E10

Forest plots of the included studies showing the pooled estimates of the mean cardiopulmonary bypass time (minutes) (A) and aortic cross-clamp time (minutes) (B). CI, Confidence interval.

Figure E11

Forest plots of the included studies showing the pooled estimates of the rates of stroke (A), renal failure (B), and new pacemaker insertion (C). CI, Confidence interval; EV, number of events; TRT, number of treated.

Figure E12

Meta-regression graph depicting the relationship between propotion of endocarditis and 30-day mortality (A), 30-day readmission (B), reoperation for bleeding (C), stroke (D), renal failure (E), and new permanent pacemaker insertion (F).