Surgical Explant of Degenerated Transcatheter Valves: A New Type of Threat?

Abstract

Objectives

Transcatheter treatment for valvular heart diseases has markedly expanded its indications due to reduced invasiveness and hospitalization time. Despite favourable results, several peculiar and more frequent shortcomings than occur with a surgical-based implant have been reported. This review provides the currently available information regarding a transcatheter heart valve (THV) implant and reoperation, focusing on recent available data about surgical management strategies for THV degeneration.

Methods

For this narrative review, we searched Medline through the end of March 2025 using medical subject headings and text words supplemented by scanning the bibliographies of recovered articles. The terms “transcatheter valve degeneration,” “TAVI degeneration,” “surgical treatment,” and “surgical explant” have been combined using the Boolean operator “AND”.

Results

Currently available articles focus specifically on the aortic THV explant. Peculiar intraoperative (like coronary ostium, aortic wall and annular injury due to THV explant) or short-term postoperative complications related to THV explant have been reported. Thirty-day mortality has been shown to range between 12% and 32.6%, and only short and heterogeneous follow-up periods are available to date. A careful work-up to indicate that the valve-in-valve procedure is not feasible or not appropriate when facing degenerated THV and a cautious, detailed plan of the surgical explant have been recently recommended.

Conclusions

THV explants due to valve degeneration are rapidly increasing, but, due to the related risk for intra- and post-procedural complications, careful preoperative evaluation and intraoperative handling are warranted.

Cardiac valve replacement remains a cornerstone of treating valves diseases, with a constant increase in biological prosthetic implants.

Graphical abstract

INTRODUCTION

Cardiac valve replacement remains a cornerstone of treating valves diseases, with a constant increase in biological prosthetic implants.¹ Nevertheless, there is also a growing interest in implanting a biological transcatheter heart valve (THV), particularly in the treatment of aortic valve diseases due to an already well-established clinical experience.² Progressive structural valve degeneration (SVD) or non-structural valve degeneration (nSVD) of implanted bioprostheses, however, has represented a major drawback in such a setting, with granular mid-term/long-term information for surgically implanted tissue valves, but with still rather limited or no information regarding THVs. Recent data from transcatheter-based studies, including randomized controlled trials, have shown that THVs might behave in a manner similar to that of surgically implanted ones with regards to SVD.^1,3 Furthermore, the possibility of repeating a transcatheter procedure, namely a valve-in-valve (ViV) implant, whether in the presence of a previously implanted THV or a surgically implanted dysfunctional valve, has also been demonstrated.⁴ Nonetheless, specific circumstances may require a surgical explant of a THV. Recent studies have raised concerns about the risks associated with an operation in such a setting, particularly in the aortic position. This narrative review focuses on current data related to THV SVD and the issues and results of a surgical explant.

METHODS

We searched Medline through the end of March 2025 using medical subject headings and text words supplemented by scanning the bibliographies of recovered articles. The terms “transcatheter valve degeneration,” “TAVI degeneration,” “surgical treatment” and “surgical explant” have been combined using the Boolean operator “AND”.

Given the extensive argumentation presented in the current manuscript and the narrative format of the review, which explores the potential use of THV explants for various valvulopathies, the authors have opted for a free-text model, utilizing Boolean operators, rather than employing a Population, Concept, and Context/Population, Intervention, Comparison, and Outcome (PCC/PICO) model.

Surgically implanted bioprosthetic valves (aortic, mitral and tricuspid) durability: the current references

The choice of an aortic bioprosthesis as first-line treatment for native valve dysfunction allows, in case of future SVD, treatment with both the transcatheter (transcatheter aortic valve implant [TAVI]-in-surgical aortic valve replacement [SAVR]) or surgical (redo-SAVR) approach.⁵ Bioprosthetic SVD represents a well-known complication after cardiac valve replacement with tissue valves, with variable time-to-degeneration events depending on patient age, comorbidities and even valve type^7,8 limiting the operator’s choice to implant a bioprosthesis, especially in patients younger than 65 years.⁶ However, favourable results with the durability of aortic bioprostheses allow us to consider this type of valve also for patients aged 50 to 65 years^9–12 (Table S1).

Despite acceptable results of freedom from SVD and survival at 10 and 15 years^13,14 (Table S2), reports of biological valves in the mitral position apparently indicate a shorter longevity than those in the aortic position.^15–17 The main reason for worse mitral valve durability seems to be the high-pressure gradient between the left atrium and the left ventricle, which leads to increased shear stress on leaflet tissue.¹⁴ Additionally, the low-flow status of the mitral valve may make the prosthesis more prone to valve thrombosis.

Although rarely performed, surgical tricuspid valve replacement with bioprostheses has been associated with satisfactory freedom from reoperation and survival in the mid to long term, as reported in Table S3.

Transcatheter aortic valve implant: mid-term durability and prosthetic degeneration

Like a surgical bioprosthesis, a THV has a variable incidence of SVD. Notably, the definition of SVD has been progressively revised over the years, leading to the more recent classification provided by the Valve Academic Research Consortium-3.¹⁸ SVD has exhibited a progressively lower incidence over the years with the evolution of the transcatheter prosthesis shape and materials^19–21; nevertheless, some procedural factors could affect THV durability. From a structural point of view, native aortic leaflets have 3 extracellular matrix layers that ensure elasticity and, through remodelling processes, a dynamic response to shear stress and haemodynamic changes. Instead, THV leaflets are engineered using bovine or porcine tissue without dynamic properties; moreover, transcatheter prosthesis leaflets are thinner than surgical ones, favouring the degenerative processes as suggested by microscopic analysis.²² Although the surgical prostheses have engineered tissue leaflets, implanting them, except for the sutureless prosthesis, does not involve valve crimping, as occurs with the THV, thereby intuitively reducing the risk of intraprocedural valve damage.²³

Another proposed mechanism leading to SVD is prosthesis deformation due to asymmetrical expansion. Conceptually, a THV is crimped in a rigid delivery system and implanted in a calcified annulus with potential asymmetrical expansion, especially for procedures where balloon pre-dilation is not performed.²⁴ However, an eccentric expansion, under-expansion or vertical deformation of THV could affect long-term haemodynamic performance by promoting shear stress-related prosthetic leaflet injury and early valve degeneration.²⁵ Besides procedural aspects, some clinical features, like female sex, young age (<60 years) and diabetes mellitus, seem to be independent risk factors for early prosthesis degeneration.²⁶ Alour and colleagues recently demonstrated that native aortic valve calcium, vitamin K antagonist (VKA) therapy and residual regurgitation after THV release are all factors that promote prosthetic dysfunction.²⁷

The aetiology of bioprosthetic valvular failure (BVF) is of critical relevance when choosing an adequate interventional approach: whereas THV endocarditis requires a mandatory surgical explant once the antimicrobial therapy is ineffective, BVF due to SVD might be treated by a ViV procedure or a TAVI explant (SAVR).¹³ ViV-TAVI for THV degeneration is a less invasive approach than a surgical one, with acceptable mid-term results.²⁸ Although the above-mentioned results could encourage an early transcatheter approach in patients with aortic prosthesis degeneration, anatomical and procedural considerations must be made before a TAVI-in-TAVI procedure. About 20% of patients have unsuitable anatomy for TAVI repetition, mainly due to unfavourable coronary or aortic root anatomy or an indication for a concomitant procedure.^29,30 Furthermore, the valve type selected for the first implant (self-expandable (SEV) or balloon expandable (BEV)) could affect the BVF treatment because of the variable hazard of the sinus of Valsalva sequestration and/or acute coronary occlusion, as well as potential issues related to the depth to which the prosthesis is implanted (neo-skirt, leaflets overhanging, conduction system disease).^29,31,32

Currently available studies show that BVF occurs frequently within 1 year, especially for mechanical reasons, like a paravalvular leak. On the contrary, beyond 12 months postoperatively, the leading mechanism for a THV explant is nSVD (patient/prosthesis mismatch or endocarditis).³⁰ A careful evaluation of the effective SVD mechanism might be made because the calcific degeneration of aortic prosthesis leaflets is not the only aetiology of SVD.

THV failure opens a challenging decision-making process for the treatment modality. Patients with TAVI often present a high-risk profile; consequently, in the case of repeated treatment, the operative risk is always higher than that of the first operation.³³ SVD was previously less of a concern because patients who underwent TAVI generally did not “outlive” their valve, posing an important competing risk for this complication.³⁴ Indeed, follow-up data from early studies on TAVI did not report detailed information on prosthesis performance. Furthermore, many available studies display data until 5 years of follow-up after TAVI.^35–37 Over this time frame, the evidence becomes progressively scarce. The NOTION (The Nordic Aortic Valve Intervention) trial provides follow-up data for up to 10 years for a population with lower risk and longer life expectancy than was observed in the early studies.³⁸ Data from a 10-year follow-up (available data from 100 patients) confirmed a low rate of all-cause mortality and a lower incidence of SVD in those who had TAVI rather than SAVR (1.5% vs 10%). Of note, 2 groups have shown a similar incidence of nSVD.³⁹ Similarly, a landmark analysis of PARTNER-2A patients by Pibarot et al.²⁶ reported an effective improvement in outcomes of patients treated with the SAPIEN-3 versus the SAPIEN-XT valve, with 5-year SVD incidence consistent with SAVR results. Although evidence on THV performance reaches 10 years after the procedure, 2 critical considerations are needed: first, patients who underwent TAVI 10 years ago have received a first-generation device that is no longer available; second, studies included high-risk populations with relatively short life expectancy, leading to a follow-up analysis performed on a small proportion of the initially treated population, as reported in Table S4. In contrast, the life expectancy of a low-risk patient is at least 20 years, and such patients are expected to “outlive” their biological valve (whether surgical or transcatheter). Therefore, BVF adjudication such as freedom from SVD (symptoms absence) and concomitant exclusion of untreatable patients from available studies, has raised concerns about BVF incidence reliability.³⁸ The updated definition of SVD, provided by the Valve Academic Research Consortium-3,⁴⁰ has led to a recent report of an effective similar incidence of all-cause BVF in patients treated with SAVR or TAVI (1–4% at 5 years and 3–10% at 10 years for both groups).¹⁸ A clinical adjudication of the SVD impact on long-term outcomes has been made in a pooled analysis of data from TAVI randomized controlled trials and registries on SEV, showing that SVD occurrence is associated with increased all-cause and cardiovascular mortality at the 5-year follow-up.¹

Transcatheter mitral valve implants and prosthetic degeneration

A transcatheter mitral valve implant (TMVI) is a recently developed therapeutic option in patients unsuitable or at high risk for an operation. Although minimally invasive therapeutic options, like transcatheter edge-to-edge repair and mitral annuloplasty, are performed successfully worldwide in patients with primary mitral regurgitation (MR), fewer transcatheter strategies are available for secondary MR and mitral stenosis. The widespread need for reducing hospitalization for heart failure also in patients with prohibitive surgical risk has led to the development of transcatheter prostheses in recent years.⁴¹ To date, aortic THV are used also for bioprosthesis failure or native stenosis in the mitral position in patients with prohibitive surgical risk and anatomical feasibility. However, new dedicated devices for TMVI have been developed. Also, less invasive strategies have been performed through femoral vein access, and a transeptal puncture has been reported to reduce the procedural risk.^42,43

Other than for the treatment of native mitral valve defects, TMVI is also a viable option to treat mitral prosthesis degeneration, avoiding a redo-surgery in patients burdened by comorbidities and relevant surgical risk profiles. Using a transcatheter mitral prosthesis for a degenerated bioprosthesis led to lower periprocedural complications and shorter hospital stays than redo surgery.⁴⁴ Early studies on TMVI durability are encouraging; however, data on treatment longevity are limited.⁴⁵ Based on current knowledge, TMVI might improve clinical outcomes, thereby reducing hospitalization for heart failure; however, the longest available follow-up is up to 2 years after the intervention, and randomized studies are lacking,⁴⁶ rendering an analysis of potential SVD rates infeasible at this moment.

Transcatheter tricuspid valve implant

In the last decade, the availability of transcatheter options for treatment of tricuspid regurgitation (TR) has resulted in improving patients’ symptoms.⁴⁷ Early clinical results from edge-to-edge repair are encouraging.⁴⁸ Recently, a dedicated device was developed for a transcatheter implant in patients with severe tricuspid regurgitation. Initial experiences for compassionate use have shown effective improvement in patients’ clinical symptoms.⁴⁹ As for the transcatheter mitral prosthesis, data on the tricuspid THV SVD and its durability are still too scarce to summarize.

Surgical reintervention in case of transcatheter valve degeneration

The incidence of a THV explant ranges between 0.4% and 1% in patients treated with transcatheter aortic valve replacement (TAVR),^30,50 with 30-day and 1-year mortality doubled compared with that for redo SAVR.⁵¹ As described in a large study by Hirji and colleagues, the early and mid-term mortality is high regardless of the BVF mechanism (endocarditis, PVL or leaflet degeneration) and independent of time between the THV implant and the reoperation.⁵² Sathananthan and colleagues have excised and haemodynamically analysed 14 THV from autopsies in patients included in the EXPLANT-TAVR Registry. The most interesting findings were a substantial correspondence between a calcified and a non-calcified prosthesis in terms of transvalvular gradients (42 vs 36 mmHg, respectively), and leaflet restriction or prosthesis intrinsic degeneration as degenerative mechanisms, other than calcifications.^30,53 Those findings potentially open a further consideration in understanding valve durability, considering a not mandatory time-degeneration relationship.⁵⁴ However, as reported in a database on over 30,000 patients with aortic stenosis, a repeated SAVR procedure after a first-line SAVR (redo-SAVR) is burdened by lower mortality (11.3% vs 6.7%) than the transcatheter approach (TAVR-in-SAVR) at the 30-day follow-up.⁵⁵ Those findings have been confirmed by Awtry and colleagues, who have compared patients with surgical valve degeneration as candidates for redo-SAVR or ViV-TAVR. The primary outcome of the study (5-year mortality) confirms a survival advantage of redo-SAVR over ViV-TAVI; however, for secondary outcomes (30-day mortality, major adverse cardiovascular events (MACE)) a less invasive procedure like ViV has shown better results than an operation.⁵⁶

The potential damage deriving from surgical intervention is tightly related to the occurrence of bioprosthetic valve dysfunction. When the THV is in place for a longer period, there is more abundant endothelization and embedment into the aortic wall and valve annulus. This wall/annulus-related involvement by the THV structure may represent a non-negligible cause of injury (aortic wall, mitro-aortic continuity, coronary arteries, membranous septum), sometimes requiring a complex reparative operation. On this topic, Brescia et al.⁵⁷ reported 0.43% incidence of a THV explant in patients having TAVI who have a low-risk profile (Society of Thoracic Surgeons [STS] score when implanted: 4.3%) and a high-risk profile on surgical reintervention (STS score at explant: 9.3%). Interestingly, patients with concomitant untreated valvular defects (mitral regurgitation, tricuspid regurgitation) have a worse outcome than those without. The increasing requests for concomitant operations have been confirmed in a systematic review by Yokoyama et al., who analysed about 1700 patients with indications of a THV explant (37.6% for endocarditis, 27.7% for SVD) from 10 studies. Globally, more than 50% of patients analysed have required a concomitant procedure; coronary artery bypass, mitral valve or aortic repair were reported as the procedures most commonly associated with prosthesis removal.⁵⁸ In a study by Fukuhara et al., 487 patients with previous TAVI (153 SEV, 330 BEV) underwent a THV explant for endocarditis, PVL or procedural failure. These results notwithstanding, in the SEV group, a higher incidence of ascending aorta replacement was reported. In this regard, if the THV endothelization moves towards the left ventricular outflow tract, the risk of damage to the ventricular septum or the anterior mitral leaflet (AML) is heightened.⁵⁹ The importance of the surgical approach to a degenerated transcatheter prosthesis is underlined by the recent publication of 2 large registries on THV surgery. The EXPLANT-TAVR, with 269 patients treated in 42 centres between 2009 and 2020, and the EXPLANTTOREDO-TAVR, have described 396 cases of THV failure in patients who have undergone redo-TAVI or THV explants in 29 centres during the period 2009 to 2022.^30,52 In the registry of Tang and colleagues, patient/prosthesis mismatch is shown as the main indication for a THV explant, whereas PVLs have a similar incidence in both the BEV and the SEV groups. At the 3-year follow-up, patient survival has a similar rate across study groups.⁵² However, the 1-year mortality rate is greater than 30%, consistent with data reported by Bapat in EXPLANT-TAVR, where the overall mortality is about 28%. Furthermore, mitral surgery, ascending aorta replacement and longer cardiopulmonary bypass times were all independent predictors of 1-year mortality.³⁰ Thus far, EXPLANTTOREDO-TAVR represents the only multicentric comparison of redo-TAVI and THV explant in patients with BVF. Analysed data on THV degeneration mechanisms and explant prognosis procedures are reported in Table 1.

Table 1.

Summary of Analysed Studies of Patients Who Underwent Surgical Explant of a Degenerated Transcatheter Aortic Valve

	Enrolment period (years)	Population (n)	Age (years)	Female (%)	STS-PROM (mean)	SVD (%)	Intra- or post-procedural complications (%)	Mortality (%)a
Hirij (2020)	2011-2018	227	73.7	35.2	NA	79.3%	CS 12.8 Stroke 5.7 PPI 13.2	13.2 (30-day) 22.9 (1-year)
Bapat (2021)	2009-2020	269	72.7	34.9	5.6	20.1	CS 54.6 Stroke 18.7 PPI 18.4	28.5 (1-year)
Bowdish (2024)	2012-2023	2972	72	38.6	NA	64	CS 56.8 Stroke 4.6 PPI 14.6	15.8 (post-op)
Brescia (2021)	2012-2020	58 (46b)	73	33	8.9	10.9	CS 65 Stroke 4 PPI 6	33 (14 months)
Fukuhara (2021)	2011-2019	17 (12)	73	35.5	8.6	23.5	CS 35	32 (3-years)
Fukuhara (2022)	2016-2019	483	72.8	38	5.8	5.7	CS 66 Stroke 5.3 PPI 13.4	18 (30-day)
Fukuhara (2023)	2012-2019	87 (34)	74.9	44	6.1	NA	CS 68 Stroke 0 PPI 8	37 (1-year)
Hawkins (2023)	2011-2022	531	75	37	7.0	NA	CS 2-4 Stroke 5	15 (in-hospital)
Fukuhara (2025)	2013-2024	110	70-73	29	3.1-9.8	33.6	CS 35 Stroke 3.6 PPI 4.5	14.5 (1-year)
Jawitz (2020)	2011-2015	123	77	38.2	>8d	11.4	CS 8.1 Stroke 3.3 PPI 14.6	17 (30-days)
Tang (2023)	2009-2022	396 (181c)	75.5	40.9	3.9	51.9	CS 55.8 Stroke 4.6 PPI 17.8	32.4 (1-year)
Zaid (2023)	2009-2022	199	73	35.7	5	24.9	CS 25-30 Stroke 6.5 PPI 14.6	36.1 (1-year)

^aData between parentheses correspond to the longest available follow-up period.

^bNumbers between parenthesis are regarding THV explant subgroup in the study population.

^cPatients with endocarditis have been excluded from the study population. The displayed value represents the percentage of patients included in the intention-to-treat population.

^dIn this study, STS-PROM values have been reported as percentages for the 3 risk categories (low, mid and high). Number shown in the table represents the category with the highest number of patients.

CS: combined surgery; NA: not available; PPI: permanent pacemaker implant;

STS-PROM: Society of Thoracic Surgeons Predicted Risk of Mortality; SVD: structural valve degeneration; THV: transcatheter heart valve.

Complications during a surgical THV explant depend on the type of indication (like SVD or endocarditis, particularly with extended infection with a para-annular abscess) and time passed from the original THV implant to the surgical explant. Furthermore, several technical intraoperative as well as perioperative risks may obviously derive from the type of complexity of the operation itself but also from the preoperative patient profile (old age, co-morbidities, the need for a planned or unexpected associated procedure).⁶⁰

Due to the relatively low incidence of the THV explant procedure, the surgeon’s experience may additionally explain the current high perioperative mortality. Expertise on how to remove/explant the degenerated THV, particularly if it has been embedded in the aortic annulus and root for a long time, must be known. It is likely that standardized procedures and increased experience related to the THV explant, such as the patient profile, due to the continuous decline of the age of the THV candidate, will likely have a positive influence on the surgical skill as well as on the lower-risk patients undergoing the THV explant.

Table 2 summarizes the aspect/factors to be carefully considered when planning and performing a surgical THV explant. The limited experience with THV explants at the mitral or tricuspid position will likely present a peculiar technical complexity and thus new potential complications to be faced and treated when operating on these new settings.

Table 2.

Aspects and Actions to be Considered for Transcatheter Heart Valve Surgical Explant Decision-Making

1. Careful preoperative surgical planning, including appropriate multidisciplinary discussion and patient informed-consent clearly explaining the risks of THV explant in case of SVD and the unfeasibility of ViV.

2. Deciding about ViV or SAVR for THV SVD balance risks and benefits of the 2 techniques must be carefully evaluated. Only if ViV is not feasible (coronary distance or other contraindications) should SAVR be indicated.

3. Long-term durability of ViV is still unknown and therefore is also important to be considered in the future. Facing another SVD of a ViV in a degenerated surgically implanted tissue valve or THV might present additional challenges.

4. Proper preoperative CT assessment including THV position, coronary ostia location, and THV stent design and position in the aorta and LVOT highly recommended.

5. Surgeon must be aware and have appropriate knowledge of how to explant the implanted THV. Published case reports showing how to collapse the type of THV to be explanted should be carefully examined/known preoperatively by the surgical team to facilitate the intraoperative procedure and to reduce as much as possible the trauma to the aorta-related structures.

6. In case of high-risk and elderly patients, priority and attempt should be given to a minimal surgical procedure (isolated prosthetic replacement), trying to avoid an associated procedure if possible.

7. Implanting a new tissue valve suitable for a future ViV, taking care to note of the location/position of the coronary ostia.

8. Haemodynamic result of the newly implanted surgical valve should also be considered to avoid PPM after the redo procedure. Aortic annular enlargement should therefore be considered wisely without increasing the surgical risk.

Abbreviations: CT: computed tomography; LVOT: left ventricular outflow tract; PPM: patient/prosthesis mismatch; SAVR: surgical aortic valve replacement; SVD: structural valve degeneration; THV: transcatheter heart valve; ViV: valve-in-valve.

Randomized studies comparing a surgical THV explant to ViV will be extremely difficult to design and perform. Registry data (like REVALVE or RETAVI) will hopefully provide meaningful information and enhance the indications in the setting of THV management.

Temporal trends and current evidence

The THV explant is the fastest growing cardiac procedure in the United States. The renewed interest in the explant procedure is justified for many reasons: (1) An earlier reintervention in patients without transcatheter feasibility, although with high risk due to comorbidities and advanced age, may be related to a substantial improvement in clinical conditions, thereby avoiding ominous consequences (end-stage heart failure); (2) the increasing request for this type of operation, as observed in recent studies displaying a substantial increase in THV explant interventions.^29,33,61 Several reports have shown the recent trend towards surgical intervention for degenerated THV, mostly with infective endocarditis, whereas information about SVD and PVL is lacking in about 50% of considered studies.⁶² An expert consensus report on explant techniques has recently been released by leading experts in the field, underlying the critical role of preoperative computed tomography scans to evaluate the degree of THV adhesions and the cross-clamp zone.⁶³

Our review addresses some of those unmet needs. Notably, the included studies focus primarily on SVD, with only 1 study not providing explicit indications for a THV explant. To mitigate potential high population heterogeneity, studies lacking information on degeneration mechanisms, even when analysing a large population (such as studies by Hawkins and Percy), have been excluded from the current work. Estimated mortality rates have been reported also beyond 30 days in a population composed exclusively of patients with THV explants. Moreover, analysed studies have enrolled patients with a mean STS-PROM between 4% and 9%, which falls within the evidence-scarce region, as reported in both European and American guidelines. This review also highlights the limited evidence on THV mitral and tricuspid valves, emphasizing the need to consider durability and long-term implications of transcatheter treatment of other valves beyond the aortic valve.

Long-term survival after a THV explant is maybe the more contemporary issue, considering the established increase in TAVI surgery requests and the concomitant need for a prognostic improvement.⁶⁴ This concept has been enforced by a recent analysis of French registries, including more than 72,000 patients who had the TAVR procedure, that has shown that the overall mortality of patients with THV explants is independent of the surgical time (before or after 1 year from the implant procedure) and prosthesis technology (first-, second- and third-generation valves have been included).⁶⁵

CONCLUSIONS

THVs are burdened by the same degenerative mechanism affecting surgical prostheses, at a rate potentially similar to that of surgically implanted valves. A THV explant is characterized by a peculiar and heightened procedural risk. A deeper understanding of the THV’s SVD process may improve eventual treatment selection and strategy. However, dedicated studies are warranted to obtain insights about THV durability and explant-related risks, also at mitral and tricuspid positions. Safer and more effective patient-based operative planning is paramount in this setting, as is the consideration of factors likely to impact the intraoperative procedure, all of which might have a significant influence on the perioperative outcome. A standardized/prognosis-oriented approach, therefore, should be instituted in these complex settings. Current data indicate that the TAVI explant, as a surgical procedure with high in-hospital morbidity and mortality, is becoming a critical part of daily practice and therefore requires a specific multi-disciplinary and informed-consent–related discussion.

AUTHOR CONTRIBUTIONS

Giuseppe Verolino (Conceptualization, Data curation, Formal analysis, Methodology, Validation, Writing—original draft, Writing—review and editing), Michele Di Mauro (Methodology, Formal analysis, Validation, Writing—review and editing), Martin Czerny (Validation, Writing—review and editing), Michal Kawczynski (Validation, Writing—review and editing), Samuel Heuts (Validation, Writing—review and editing), Elham Bidar (Validation, Writing—review and editing), and Roberto Lorusso (Conceptualization, Data curation, Methodology, Supervision, Validation, Writing—review and editing, Writing—review and editing)

SUPPLEMENTARY MATERIAL

Supplementary material is available at ICVTS online.

FUNDING

None declared.

CONFLICTS OF INTEREST

None declared for the manuscript content.

DATA AVAILABILITY

No new data were generated or analysed in support of this research.