Patients who undergo surgical aortic valve replace (SAVR) after failed TAVR may have worse-than-expected outcomes compared with similar patients who initially have SAVR, according to a study published June 10 in JACC: Cardiovascular Interventions.

Oliver K. Jawitz, MD, et al., used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients who received TAVR prior to undergoing SAVR between 2011 and 2015. Patients were stratified according STS Predicted Risk of Mortality (STS PROM) scores at the time of SAVR reoperation, using established risk categories of low risk (STS PROM <4%), intermediate risk (STS PROM 4-8%) and high risk (STS PROM >8%). The researchers looked at baseline characteristics, operative characteristics and outcomes overall and in each risk group. Outcomes were evaluated based on the SAVR indication and the time between the index TAVR and following SAVR procedures. The researchers calculated observed to expected (O/E) mortality rations to compare across different SAVR indications and timing from the TAVR procedure.

A total of 123 patients who underwent SAVR after TAVR were identified. Of these, 21 patients (17%) were in the low-risk STS PROM group, 30 patients (24%) were in the intermediate group and 72 patients (59%) were in the high-risk group. In the weeks before the SAVR procedure, 94 patients (76%) had heart failure (HF) symptoms.

Among patients who underwent SAVR reoperation, the most common indications were TAVR valve-related issues (15%), structural prosthetic deterioration (11%), failed repair (11%), sizing or position issues (11%) and prosthetic valve endocarditis (10%). Data on the time between the TAVR and SAVR procedures were available for 58 patients. Of these, 21 patients (17%) died within 30 days of the procedure or prior to hospital discharge, including 14% of patients at low risk, 10% at intermediate risk and 21% at high risk. In-hospital death was more common among patients who required reoperation for endocarditis (25%) or perivalvular leak, sizing or position problem, or failed repair (24%), compared with patients with prosthetic deterioration (15%).

The observed mortality was higher than expected across all three risk groups, including those at low risk (O/E ratio, 5.48; 95% Confidence Interval [CI], 1.17-13.93), intermediate risk (O/E ratio, 1.66; 95% CI, 0.35-4.40), and high risk (O/E ratio, 1.16; 95% CI, 0.68-1.79). Mortality rates were also higher than expected for all reoperation indications. There were no significant differences in O/E ratios based on reoperation indications or time between TAVR and SAVR.

According to the researchers, SAVR following TAVR is associated with worse-than-expected outcomes, possibly related to the removal of the TAVR device. As TAVR becomes more common among low-risk patients who could become SAVR candidates if TAVR fails, "it may be necessary to incorporate previous TAVR in future STS PROM models," they note, adding that additional research is necessary to refine preoperative techniques and share best practices. "Continued experience with this developing technology will help to further define optimal treatment options in the setting of failed TAVR prostheses," they conclude.

The study's findings suggest that SAVR following failed TAVR is "technically more challenging than a standard SAVR," Thomas E. MacGillivray, MD, and Michael J. Reardon, MD, FACC, write in a accompanying editorial comment. "Before embarking on a strategy of TAVR in younger low risk patients, consideration of the risks of morbidity and mortality of subsequent procedures should be part of the shared decision-making," they write.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Aortic Valve, Transcatheter Aortic Valve Replacement, Reoperation, Patient Discharge, Hospital Mortality, Decision Making, Prosthesis Failure, Endocarditis, Heart Failure, Prostheses and Implants

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