Increased Risk of Surgical Aortic Valve Replacement After Prior Transcatheter Versus Surgical Aortic Valve Replacement with Concomitant Valve Disease.

Background: The etiology of increased risk for reoperation after transcatheter aortic valve replacement (TAVR) versus prior surgical aortic valve replacement (SAVR) is poorly understood. This study evaluated the impact of concomitant mitral and tricuspid valve disease on associated risk of TAVR explant.

Methods: Patients undergoing aortic valve replacement after prior SAVR or TAVR were extracted from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). Patients were stratified by TAVR explant status and presence of severe concomitant valve disease for analyses. Risk adjustment was performed using multivariable logistic regression. Interaction terms were utilized to evaluate differential risk of concomitant valve disease for TAVR explant versus redo-SAVR.

Results: Of 24,097 redo aortic valve replacement patients, 877 (3.6%) underwent TAVR explant. TAVR explant patients had higher rates of concomitant severe valve disease (17% vs 14%, p<0.001). Patients with severe concomitant valve disease had worse operative mortality after TAVR explant (26.2% vs 14.6%, p<0.001) and redo-SAVR (12.3% vs 6.9%, p<0.001). TAVR explant was independently associated with higher mortality (OR 1.3 [1.0-1.6], p=0.030). Severe mitral regurgitation (OR 1.2 [1.0-1.6], p=0.017), mitral stenosis (OR 2.0 [1.5-2.7, p<0.001), and tricuspid regurgitation (OR 1.6 [1.3-1.9], p<0.001) were all associated with mortality, although these factors were not associated with disproportionately higher risk during TAVR explant (p>0.05).

Conclusions: TAVR explant cases have a higher burden of severe concomitant valve disease than redo-SAVR cases. Heart teams should consider these findings when discussing initial procedure choices for patients with multi-valve disease given their extreme risk at time of TAVR explant.