Surgical explantation of failed transcatheter heart valves: indications and results.

Given the recent surge in transcatheter heart valve replacement (THVR), cardiac surgeons will surely face the challenge of eventual explantation. The aim of this study was to determine indications for reoperation, while exploring pertinent technical aspects and survival after THV explantation in a cohort originally deemed high risk or even inoperable. Between February 2008 and March 2019, 31 patients with failed transcatheter aortic valve replacement (TAVR) underwent surgical explantations at our facility. Data were prospectively collected for retrospective analysis of procedural indications, technical issues, and postoperative survival. The major reason for TAVR removal was bioprosthetic valve failure (BVF) due to infective endocarditis (IE: 16/31 [51.6%]), non-structural (NSVD: 14/31 [45.2%]) and structural (SVD: 1/31 [3.2%]) valve deterioration accounting for the rest. Mean age at THV explantation was 76.3 ± 8.3 years, and median time from TAVR to explantation was 153 days (0 days-56.6 months). Median ICU and hospital stay were 6 days (1-44 days) and 23 days (8-62 days), respectively. Thirty-day and 1-year survival rates were 74.2% and 67.2%, respectively. Median follow-up interval after explantation was 364 days (3 days-80 months). Mean cardiopulmonary bypass time was 124.6 ± 46.8 min, and mean aortic cross-clamp time was 84.3 ± 32.9 min. There was no need for unplanned aortic root repair owing to tissue damage during dissection of the TAVR from surrounding tissue. The most common reason for THV explantation was (a) BVF for IE and (b) BVF secondary to NSVD. Although 30-day and 1-year mortality rates in this multimorbid cohort were predictably high, no procedural mortalities occurred.

Safety and efficacy of the subclavian access route for TAVI in cases of missing transfemoral access.

OBJECTIVE: We retrospectively analysed our experience with the subclavian access transcatheter aortic valve implantation (TAVI) with the self-expandable CoreValve prosthesis and compared the results with transfemorally treated patients. BACKGROUND: For TAVI, a subclavian access is alternatively used when the femoral arteries are diseased or very small. METHODS: Between June 2007 and February 2011, 341 patients underwent CoreValve implantation in the German Heart Center, Munich through either transfemoral (n = 301) or subclavian (n = 40) approach. The subclavian approach was chosen where transfemoral approach was not possible. RESULTS: There was no difference in baseline characteristics between the groups. There were no significant differences between groups for parameters potentially related to improved valve positioning (contrast medium, fluoroscopy time, implantation of a second valve, post-implantation balloon dilatation, valve dislocation, pacemaker implantation, aortic regurgitation), while the procedure duration was longer (105 ± 40 vs. 82 ± 33 min, p = 0.001). With the Kaplan-Meier estimate, survival was not different among groups. Strokes, myocardial ischaemia, and access vessel complications occurred in 2.5, 0, and 7.5 % (subclavian group) vs. 4.3, 2.0, 10.6 % (transfemoral group), ns. CONCLUSIONS: Our results demonstrate the safety of the subclavian access for TAVI and comparability with the transfemoral approach. With longer duration of the procedure and no significant advantages in clinical outcome, the subclavian access will have an indication for selected patients, while transfemoral TAVI should be considered first choice.