Abstract
Objective
Over the past decade, there has been a dramatic growth in the utilization and diversity of available transcatheter devices for the replacement and repair of all heart valves. The aim of this study is to examine temporal trends, failure profiles, and clinical outcomes involved in the surgical explantation of transcatheter valve prostheses.
Methods
Adult patients undergoing surgical explantation of transcatheter valve prostheses between 2014 and 2022 at a single institution were identified. Retrospective cohort review and survival analysis were performed to assess patient characteristics, indications for explant, and operative outcomes.
Results
From 2014 to 2022, 8 surgeons at a single institution performed explantation of transcatheter valve prostheses in 44 patients. Among explanted devices, 50% were removed within 1 year of transcatheter implantation. Surgical explantation was performed on an urgent or emergent basis in 57% of patients. Indications for explantation included valve prosthesis failure (57%), iatrogenic injury (16%), and endocarditis (11%). Operative mortality was 11%, with a mean Society of Thoracic Surgeons mortality risk of 12%. Patients undergoing elective explantation had improved survival compared with those undergoing urgent or emergent explantation (P = .03). Overall survival was 77% at 3 years following transcatheter valve explantation.
Conclusions
There is a rising annual incidence of transcatheter valve explantation in all valve positions. Surgical explantation performed on both elective and non-elective bases is increasingly common in adult cardiac surgical practice. The clinical impact of transcatheter valve explantation is significant and should be strongly considered by multidisciplinary heart teams in the lifetime management strategy of cardiac valvular disease.
Key Words: surgical explantation, TAVR, TEER, transcatheter valve
Graphical Abstract
Surgery to explant transcatheter valves has increased significantly in the past decade.
Central Message.
Surgical explantation of transcatheter heart valves is increasingly common, the risks of which must be carefully considered when selecting lifetime management strategies for valvular heart disease.
Perspective.
The continued adoption of new transcatheter valve therapies has been accompanied by a dramatic growth in the need for their surgical explantation. The associated risks and clinical impact of transcatheter valve explantation are significant and should be strongly considered by multidisciplinary heart teams in the selection of both initial and lifetime management strategies for valvular heart disease.
Over the past decade, the advent and growing adoption of transcatheter technologies have drastically changed the landscape of treatment for valvular heart disease. Initially developed as alternatives for high-risk patients unsuitable for traditional surgery, transcatheter valve prostheses have broadened the range of treatment options available for valvular repair and replacement.1,2 Today, transcatheter valve prostheses are available to address disease in all 4 heart valves (aortic, mitral, tricuspid, and pulmonary)3, 4, 5, 6, 7, 8 and their scope of use has extended beyond the originally older and sicker population to now include younger and low-risk patients.9
With the rising utilization of transcatheter valve prostheses in younger patients, recent attention has turned towards the increasing clinical need for surgical explantation of these devices. In particular, surgical aortic valve replacement (SAVR) after transcatheter aortic valve replacement (TAVR) is now the fastest growing cardiac surgical procedure in the United States and is associated with a 1.74 times increased risk of mortality versus SAVR after SAVR.10,11 Likewise, data from international registries on mitral surgery after failed transcatheter edge-to-edge repair (TEER) demonstrate a 16% operative mortality with 93% of these patients having to undergo replacement rather than repair of their mitral valve.12 Although the optimal modality to treat valvular heart disease in low- and intermediate-risk patients remains widely debated, the placement of transcatheter valve prostheses in this population continues to rise. Whether appropriate or not, the increasing use of transcatheter valve prostheses has led to an increased expectation for their eventual explantation, especially in young patients.
The growing experience of surgical explantation for transcatheter heart valves is continuing to expand. In the present study, we share our institutional experience over the past decade to characterize temporal trends, failure profiles, and clinical outcomes following the surgical explantation of transcatheter valve prostheses in all valve positions.
Material and Methods
Study Design
We retrospectively reviewed our institutional cardiac surgery database to identify all adult patients who underwent surgical explantation of transcatheter heart valve prostheses at our institution between January 1, 2014, and December 31, 2022. All aspects of the study were approved by the Stanford University Institutional Review Board (IRB59157 approved 7/25/23), and the requirement for informed consent was waived. Exclusion criteria included patients aged less than 18 years and those undergoing cardiac surgery without transcatheter prosthesis explantation. Clinical characteristics and operative outcomes were reported for all patients including baseline demographics, indications for explantation, postoperative complications, and survival.
Surgical Technique
Explantation of transcatheter valve prostheses was performed in accordance with individual surgeon experience. General principles for valve prosthesis explantation include careful dissection of devices away from surrounding structures to minimize disruption to the aorta, valve leaflets, membranous septum, and atrioventricular grooves. Neoendothelialization in the setting of explantation presents more challenging identification of surgical tissue planes, particularly in older valve devices. TAVR explantation was commonly performed using a double Kocher clamp technique,13 with the addition of an involution maneuver whereby both clamps are rotated inwards to deform the nitinol cage away from the aorta (Video 1). MitraClip explantation was performed with sharp excision of the prostheses away from engaged mitral leaflet edges (Video 2) and often precluded amenability for mitral valve repair, particularly in cases where multiple clips were deployed and subsequently excised from the anterior mitral leaflet. On occasion, mitral valves were assessed to be repairable when the MitraClip device had disengaged or failed to engage the anterior leaflet.
Data Definitions
Operative mortality was defined as death from any cause during hospitalization or within 30 days of surgical explantation. The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated from the STS Adult Cardiac Surgery Database operative risk calculator at the time of explantation and was not available for a subset of patients undergoing multiple valve or concomitant aortic surgery. Low-, intermediate-, and high-risk patients were defined as having STS-PROM less than 4%, between 4% to 8%, and greater than 8%, respectively. Patients undergoing explantation for recurrent, persistent, or new valvular stenosis or regurgitation were classified as having prosthesis degeneration or failure. Patients undergoing aortic root enlargement or replacement of any of the aortic root, ascending aorta, or aortic arch were categorized as having a concomitant aortic procedure in addition to primary valve explantation. Early explantation was defined as explantation performed within 1 year of transcatheter implantation, whereas late explantation was performed more than 1 year after implantation.
Statistical Analysis
All data are presented as n (%) for categorical variables and mean ± SD or median (interquartile range) for continuous variables. Bivariate analyses were conducted using Pearson's chi-square or Fisher exact tests for categorical variables, and 2-tailed Student t test or Mann–Whitney U test for continuous variables. Normality was assessed by skewness, kurtosis, and the Shapiro–Wilk test. Post-explantation survival was analyzed using the Kaplan–Meier method with a log-rank test for between group differences. Long-term follow-up was dated to the latest documented clinical encounter in the health record, and patients were censored from analysis at the date of their last known contact. All statistical analyses were performed using STATA/SE v17.0 (StataCorp LLC).
Results
Trends in Explantation
From 2014 to 2022, 8 surgeons at our institution performed explantation of transcatheter valve prostheses in 44 patients (Figure 1). The annual frequency of transcatheter prosthesis explantation increased from 1 in 2014 to 11 in 2022. Transcatheter heart valve prostheses were most commonly explanted from the mitral position (21/44, 48%), followed by the aortic (18/44, 41%), pulmonic (3/44, 7%), and tricuspid (2/44, 5%) positions. Explanted devices included 11 primary TAVRs, 7 valve-in-valve TAVRs, and 18 MitraClips (Abbott). Across all explanted transcatheter valve prostheses, 50% (22/44) were explanted within 1 year of transcatheter implantation (Figure 2).
Figure 1.
Annual frequency and distribution of transcatheter valve explantation by year. TAVR, Transcatheter aortic valve replacement; TEER, transcatheter edge-to-edge repair; TMVR, transcatheter mitral valve replacement; TTVR, transcatheter tricuspid valve replacement; TPVR, transcatheter pulmonary valve replacement.
Figure 2.
Time from transcatheter valve implantation to surgical explantation.
Patient Characteristics
Patient demographics and clinical characteristics are summarized in Table 1. The median age of patients undergoing explantation was 70 years, with 39% (17/44) of patients being female. By the time of explantation, 25% (11/44) of patients had a permanent pacemaker in place and 25% (11/44) had a history of myocardial infarction. The median ejection fraction was 55%, and 77% (34/44) of patients presented with New York Heart Association functional class III/IV heart failure. There was a trend toward younger age (64.5 vs 71 years, P = .08) and lower ejection fraction (49.5% vs 60%, P = .03) in patients undergoing late versus early explantation, with otherwise similar baseline demographics and comorbidities between groups. Among patients with available scores (n = 24), the overall median STS-PROM was 9%, with a larger proportion of early explantations being high risk (STS-PROM >8%).
Table 1.
Baseline patient characteristics
| Variable | Overall (n = 44) | Early explant (<1 y, n = 22)∗ |
Late explant (>1 y, n = 22)† |
P value |
|---|---|---|---|---|
| Age, y | 70 [60.5-79] | 71 [66-81] | 64.5 [58-74] | .08 |
| Female | 17 (39) | 11 (50) | 6 (27) | .21 |
| Hypertension | 34 (77) | 4 (18) | 6 (27) | .72 |
| NYHA Class III/IV | 33 (75) | 18 (82) | 15 (68) | .49 |
| Ejection fraction, % | 55 [41-60] | 60 [50-68.7] | 49.5 [30-58] | .03 |
| Persistent atrial fibrillation | 6 (14) | 3 (14) | 3 (14) | 1.00 |
| Permanent pacemaker | 11 (25) | 4 (18) | 7 (32) | .49 |
| Cerebrovascular disease | 3 (7) | 2 (9) | 1 (5) | 1.00 |
| Prior stroke | 2 (5) | 1 (5) | 1 (5) | 1.00 |
| Prior myocardial infarction | 11 (25) | 6 (27) | 5 (23) | 1.00 |
| Current smoker | 2 (5) | 0 | 2 (9) | .49 |
| Chronic lung disease | 17 (39) | 10 (45) | 7 (32) | .54 |
| Diabetes | 16 (36) | 8 (36) | 8 (36) | 1.00 |
| Dialysis | 5 (11) | 4 (18) | 1 (5) | .35 |
| Peripheral vascular disease | 3 (7) | 2 (9) | 1 (5) | 1.00 |
| STS-PROM‡ | ||||
| Low (<4%) | 3 (13) | 1 (7) | 2 (20) | .55 |
| Intermediate (4%-8%) | 9 (38) | 5 (36) | 4 (40) | 1.00 |
| High (>8%) | 12 (50) | 8 (57) | 4 (40) | .68 |
Values are presented as n (%) or median [interquartile range] unless otherwise indicated. NYHA, New York Heart Association; STS-PROM, Society of Thoracic Surgeons Predicted Risk of Mortality.
n = 14 with available STS-PROM.
n = 10 with available STS-PROM.
n = 24 with available STS-PROM.
Indications of Explantation
Transcatheter valve devices and indications for explantation are summarized in Table 2. The most common reason for surgical explantation was transcatheter valve prosthesis degeneration or failure (25/44, 57%) (Figure 3), with a trend towards higher prevalence in patients undergoing late explantation (73% vs 41%, P = .07) (Table 2). Iatrogenic injury from transcatheter implantation was the second most common indication for explantation overall and accounted for 32% (7/22) of all early explantations. Additional reasons for explantation included endocarditis (5/44, 11%) and device embolization or migration (4/44, 9%). One patient underwent explantation for late-onset presentation of type A aortic dissection 10 months after their TAVR, with a chronic proximal intimal tear found to be originating from the edge of the TAVR cage. One patient aged less than 50 years with a history of mediastinal radiation requested to have their TAVR bioprosthesis re-replaced with a mechanical aortic valve at the time of elective mitral valve replacement and coronary artery bypass grafting (CABG) given their age and limited durability of the TAVR.
Table 2.
Explanted devices and indications for explantation
| Variable | Overall (n = 44) | Early explant (<1 y, n = 22) |
Late explant (>1 y, n = 22) |
P value |
|---|---|---|---|---|
| Explant position | ||||
| Aortic | 18 (41) | 8 (36) | 10 (45) | .76 |
| Mitral | 21 (48) | 13 (59) | 8 (36) | .23 |
| Tricuspid | 2 (5) | 1 (5) | 1 (5) | 1.00 |
| Pulmonic | 3 (7) | 0 | 3 (14) | .23 |
| Explant device∗ | ||||
| TAVR | 11 (25) | 7 (32) | 4 (18) | .49 |
| TAVR-ViV | 7 (16) | 1 (5) | 6 (27) | .10 |
| Mitral TEER | 18 (41) | 12 (55) | 6 (27) | .12 |
| TMVR | 3 (7) | 1 (5) | 2 (9) | 1.00 |
| TTVR | 1 (2) | 1 (5) | 0 | 1.00 |
| Tricuspid TEER | 1 (2) | 1 (5) | 0 | 1.00 |
| TPVR | 3 (7) | 0 | 3 (14) | .23 |
| Indication for explantation | ||||
| Valve/prosthesis failure | 25 (57) | 9 (41) | 16 (73) | .07 |
| Iatrogenic injury | 7 (16) | 7 (32) | 0 | .01 |
| Endocarditis | 5 (11) | 1 (5) | 4 (18) | .35 |
| Device migration/malpositioning | 4 (9) | 3 (14) | 1 (5) | .61 |
| Need for other cardiac surgery | 2 (5) | 1 (5) | 1 (5) | 1.00 |
| Aortic dissection | 1 (2) | 1 (5) | 0 | 1.00 |
Values are presented as n (%) or median [interquartile range] unless otherwise indicated. TAVR, Transcatheter aortic valve replacement; ViV, valve-in-valve; TEER, transcatheter edge-to-edge repair; TMVR, transcatheter mitral valve replacement; TTVR, transcatheter tricuspid valve replacement; TPVR, transcatheter pulmonary valve replacement.
Mitral TEER, MitraClip (Abbott); Tricuspid TEER, MitraClip (Abbott); TPVR, Melody valve (Medtronic).
Figure 3.
Indications for transcatheter valve explantation.
Operative Details of Explantation
Operative details of explantation are summarized in Table 3. Surgical explantation of transcatheter valve prostheses was performed via first time sternotomy in 48% (21/44) of patients and via redo-sternotomy in 45% (20/44) of patients. Explantation was performed on an urgent or emergent basis in 57% (25/44) of patients, which accounted for 82% (18/22) of early explantations. Median aortic crossclamp time was longer in patients undergoing late explantation (130 vs 92 minutes, P = .02), without significant differences in median cardiopulmonary bypass time (194 vs 179 minutes, P = .55). In addition to transcatheter prosthesis explantation and primary valve repair or replacement, concomitant surgical procedures were performed in 68% (30/44) of patients. Patients most commonly underwent transcatheter explantation combined with simultaneous aortic surgery (11/44, 25%) including aortic root enlargement, root replacement, or ascending arch replacement. During explantation, 18% (8/44) of patients underwent CABG, and 33% (7/21) of patients undergoing mitral surgery received concomitant tricuspid valve repair. Among 18 patients undergoing MitraClip explantation, 17% (3/18) received mitral valve repair and the remainder underwent mitral valve replacement.
Table 3.
Operative details of explantation surgery
| Variable | Overall (n = 44) | Early explant (<1 y, n = 22) |
Late explant (>1 y, n = 22) |
P value |
|---|---|---|---|---|
| Status | ||||
| Elective | 19 (43) | 4 (18) | 15 (68) | .002 |
| Urgent | 15 (34) | 9 (41) | 6 (27) | .53 |
| Emergency/salvage | 10 (23) | 9 (41) | 1 (5) | .009 |
| Operative approach | ||||
| First-time sternotomy | 21 (48) | 13 (59) | 8 (36) | .23 |
| Redo-sternotomy | 20 (45) | 8 (36) | 12 (55) | .36 |
| Right minithoracotomy | 3 (7) | 1 (5) | 2 (9) | 1.00 |
| Operative details | ||||
| CPB time, min | 184.5 [131.5-223] | 179 [114-224] | 194 [132-222] | .55 |
| Crossclamp time, min | 100.5 [80-150] | 92 [70-120] | 130 [93.5-160] | .02 |
| Circulatory arrest | 3 (7) | 2 (9) | 1 (5) | 1.00 |
| Primary valve procedure | ||||
| AVR | 18 (41) | 8 (36) | 10 (45) | .76 |
| MVR | 18 (41) | 10 (45) | 8 (36) | .76 |
| MVr | 3 (7) | 3 (14) | 0 | .23 |
| TVR | 2 (5) | 1 (5) | 1 (5) | 1.00 |
| PVR | 3 (7) | 0 | 3 (14) | .23 |
| Concomitant procedures | 30 (68) | 15 (68) | 15 (68) | 1.00 |
| Aorta | 11 (25) | 4 (18) | 7 (32) | .49 |
| CABG | 8 (18) | 3 (14) | 5 (23) | .70 |
| AVR | 4 (9) | 2 (9) | 2 (9) | 1.00 |
| MVR | 4 (9) | 2 (9) | 2 (9) | 1.00 |
| TVr | 7 (16) | 4 (18) | 3 (14) | 1.00 |
| TVR | 1 (2) | 1 (5) | 0 | 1.00 |
| Maze | 4 (9) | 2 (9) | 2 (9) | 1.00 |
| VSD repair | 2 (5) | 2 (9) | 0 | .49 |
Values are presented as n (%) or median [interquartile range] unless otherwise indicated. CPB, Cardiopulmonary bypass; AVR, aortic valve replacement; MVR, mitral valve replacement; MVr, mitral valve repair; TVR, tricuspid valve replacement; PVR, pulmonary valve replacement; CABG, coronary artery bypass grafting; TVr, tricuspid valve repair; VSD, ventricular defect.
Outcomes After Explantation
Postoperative outcomes after surgical explantation are summarized in Table E1. There was an overall median STS-PROM of 9%, mean STS-PROM of 12%, and operative mortality of 11% (5/44). After explantation, 14% (6/44) of patients required support with extracorporeal membrane oxygenation, and 20% (9/44) of patients had a postoperative intra-aortic balloon pump. Duration of mechanical ventilation, time in the intensive care unit, and postoperative length of stay were similar between patients undergoing early versus late explantation. At a median follow-up of 21.1 months, overall survival was 83% (CI, 68-92) at 1 year and 77% (CI, 56-89) at 3 years after transcatheter valve explantation (Figure 4). Patients undergoing elective explantation had improved survival compared with those undergoing urgent or emergent explantation (log-rank P = .03) (Figure E1).
Figure 4.
Kaplan–Meier curve of survival after transcatheter valve explantation.
Figure E1.
Kaplan–Meier curves of survival after elective versus urgent or emergent transcatheter valve explantation.
Discussion
In the present study, we contribute our broad institutional experience with the surgical explantation of transcatheter valve prostheses (Figure 5). Over the past decade, we have observed a marked increase in the annual incidence of transcatheter valve prosthesis explantation across all valve positions, the most frequent of which were MitraClip and TAVR devices. Explantation of transcatheter valves has been increasingly performed on both elective and nonelective bases, with prosthesis degeneration or failure and iatrogenic injury representing the 2 most common indications for explantation. In our institutional series, 50% of all explanted transcatheter devices were removed within the first year of transcatheter implantation. Operative mortality after explantation was 11%, aligning with the high predicted risk of mortality of 12%.
Figure 5.
Graphical abstract. TAVR, Transcatheter aortic valve replacement; TEER, transcatheter edge-to-edge repair; TMVR, transcatheter mitral valve replacement; TTVR, transcatheter tricuspid valve replacement; TPVR, transcatheter pulmonary valve replacement.
The spectrum of transcatheter valve therapies available today is broad and only continues to expand both in the diversity of available devices and their approved indications for use. Since the implantation of the first Melody transcatheter pulmonary valve in 2000,14 the first TAVR in 2002,15 and the first MitraClip in 2003,16 next-generation transcatheter devices including the Tendyne (Abbott), Evoque (Edwards), and TriClip (Abbott) systems have emerged for mitral valve replacement, tricuspid valve replacement, and tricuspid TEER, respectively. Although the latest studies evaluating these technologies, including the Expanded Clinical Study,5 TRISCEND,7 and TRILLUMINATE trials,6 have all assessed safety and symptom reduction in elderly and highly comorbid patients, approval by the US Food and Drug Administration is expected to open the door for future trials in lower-risk patients traditionally treated with open surgery.
The marked rise of transcatheter valve explantation seen in our present study parallels the rise in transcatheter prosthesis use overall, commensurate with growing literature on TAVR and MitraClip explantation. Contemporary registry data from the STS ACSD indicate that the incidence of TAVR explantation with redo SAVR is increasing exponentially and has nearly tripled to more than 800 cases per year in 2023 after low-risk TAVR approval in 2019.10 In our study, 39% of TAVR explants were performed for valve-in-valve TAVRs, consistent with the 33% proportion of TAVR-in-SAVR explantation reported among 46 patients comprising the Michigan statewide experience of TAVR explantation.17 Mortality in patients requiring TAVR explantation has been demonstrably high, ranging from 12% mortality for valve-in-valve TAVR explantation to 14% to 17% mortality for overall TAVR explantation, in comparison with the lesser 6% to 9% mortality in patients undergoing second-time SAVR.11,18,19 Together, these data highlight that index TAVR and even valve-in-valve TAVRs may not be as durable of treatment options as initially hoped and may in fact necessitate to higher mortality reinterventions for patients long term.
Alongside the rise of SAVR after TAVR, the explantation of transcatheter mitral prostheses has grown significantly and was in fact the most common location of prosthesis explantation in our series. STS ACSD registry analysis of mitral surgery after failed TEER indicates that MitraClip explantation has more than tripled from less than 40 cases in 2015 to more than 120 cases per year in 2019.20 In our series, mitral valve repair was achieved in 17% of patients undergoing MitraClip explantation, consistent with multicenter level studies demonstrating that more than 90% of patients with failed TEER subsequently require replacement rather than repair of their mitral valves.12,20 In the international CUTTING-EDGE registry of TEER failure, although the median STS-PROM for patients undergoing MitraClip explantation had been 4% at the time of initial TEER, operative mortality after explantation reached 16% after explantation for TEER failure. Especially in young and low-risk patients, it is important to consider that initial attempts at treatment with transcatheter therapies can complicate future surgical options for those who may have had otherwise repairable valves.
While transcatheter valve therapies can be excellent treatment options for elderly and high-risk patients unable to tolerate surgery, the risks associated with future explantation surgery must be considered carefully in young patients who are expected to outlast the durability of their transcatheter devices. By the time of transcatheter prosthesis degeneration, many young patients will have gone on to develop additional cardiovascular pathologies including coronary artery disease and additional or multivalvular disease. In our study, 68% of patients required additional concomitant cardiac surgery including CABG and surgery of valves outside the primary position of explantation. In the setting of TAVR, national STS data indicate that 56% of patients undergoing explantation require additional cardiac procedures, and concomitant surgery is associated with an elevated mortality of 24% versus 14% for patients undergoing isolated SAVR after TAVR.18 Likewise, between 32% and 42% of patients undergoing MitraClip explantation undergo concomitant tricuspid valve surgery at the time of mitral valve repair or replacement.12,20 Thus, the true surgical risk of explantation in our study was likely underestimated, as calculated STS-PROM scores were not available for the 45% of patients undergoing combinations of simultaneous multivalve or aortic surgery. Especially for young patients, it is critical to avoid underuse of durable surgical therapies, including traditional mechanical prostheses, as well as new surgical advancements in the form of the Ross procedure and degenerative mitral valve repair, all of which confer significant long-term mortality benefits.21, 22, 23 With the growing array of index procedure options and subsequent combinations for reintervention in cardiac valvular disease, optimal strategies for not only initial correction but also lifetime management of valvular heart disease must be strongly considered by multidisciplinary heart teams and be discussed thoroughly with patients in shared decision-making.
Study Limitations
There are several limitations in the present study related to its retrospective and descriptive nature. First, our study cohort includes a heterogenous population of patients combining outcomes of treatments for multiple valve pathologies. Although explantation of different transcatheter devices has different technical considerations and expected outcomes, we found value in describing surgical explantation of these devices as a whole to provide broader insights to shared trends and challenges in the treatment of valvular heart disease. The small sample size of this study is limited to a single institution experience; however, our center-level findings are commensurate with those reported in larger studies of separate device explantations and contribute to the growing body of literature for transcatheter explantation surgery.
Conclusions
Surgical explantation of transcatheter heart valve prostheses is now increasingly performed in all valve positions. The continued development and use of new transcatheter technologies will make explantation surgery increasingly common in adult cardiac surgical practice. Transcatheter explantation surgery is complex and often performed concomitantly with simultaneous aortic, multivalvular, and coronary artery bypass surgery. The need for transcatheter explantation surgery is associated with high morbidity and mortality, the clinical impact of which should be strongly considered by multidisciplinary heart teams in the selection of lifetime management strategy for cardiac valvular disease.
Webcast
You can watch a Webcast of this AATS meeting presentation by going to: https://www.aats.org/resources/surgical-explantation-of-trans-7290.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
This study was approved by the Institutional Review Board at Stanford University under protocol #59157 approved on July 25, 2023.
Supplementary Data
Surgical technique for TAVR explantation. Two Kocher clamps are applied to the nitinol stent frame then rotated inwards to involute the TAVR cage away from the aorta. Video available at: https://www.jtcvs.org/article/S2950-6050(24)00027-5/fulltext.
Surgical technique for MitraClip explantation. After removal of 2 MitraClips, significant anterior leaflet involvement necessitated mitral valve replacement. Video available at: https://www.jtcvs.org/article/S2950-6050(24)00027-5/fulltext.
Appendix E1
Table E1.
Outcomes after explantation
| Outcome | Overall (n = 44) | Early explant (<1 y, n = 22)∗ |
Late explant (≥1 y, n = 22)† |
P value |
|---|---|---|---|---|
| Operative mortality | 5 (11) | 4 (18) | 1 (5) | .35 |
| In-hospital complications | 28 (64) | 15 (68) | 13 (59) | .76 |
| Cardiac arrest | 5 (11) | 3 (14) | 2 (9) | 1.00 |
| Postoperative IABP | 9 (20) | 5 (23) | 4 (18) | 1.00 |
| Postoperative ECMO | 6 (14) | 4 (18) | 2 (9) | .66 |
| Reoperation for bleeding/tamponade | 3 (7) | 2 (9) | 1 (5) | 1.00 |
| Atrial fibrillation | 11 (25) | 6 (27) | 5 (23) | 1.00 |
| New pacemaker | 4 (9) | 3 (14) | 1 (5) | .61 |
| Tracheostomy | 2 (5) | 1 (5) | 1 (5) | 1.00 |
| Pneumonia | 6 (14) | 3 (14) | 3 (14) | 1.00 |
| Renal failure requiring dialysis | 2 (5) | 1 (5) | 1 (5) | 1.00 |
| Stroke | 0 | 0 | 0 | - |
| ICU length of stay, h | 96.2 [45.0-163.7] | 92 [44.9-139.2] | 98.2 [67.1-167.2] | .56 |
| Duration of postoperative ventilation, h | 14.4 [9.0-30.9] | 15 [10.0-34.0] | 13.8 [6.1-24] | .48 |
| Postoperative length of stay, d | 12.5 [7.5-16] | 13 [7-17] | 12 [8-16] | .76 |
| Discharge to rehabilitation | 13 (30) | 9 (41) | 4 (18) | .19 |
| 30-d readmission‡ | 2 (5) | 1 (6) | 1 (5) | 1.00 |
| All-cause mortality | 8 (18) | 5 (23) | 3 (14) | .70 |
| Follow-up, mo‡ | 21.1 [12.3-36.8] | 19.4 [9.4-42.8] | 21.1 [13.1-35.4] | .97 |
Values are presented as n (%) or median [interquartile range] unless otherwise indicated. IABP, Intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit.
n = 18 with available STS-PROM.
n = 21 alive at discharge.
n = 39 alive at discharge.
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Associated Data
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Supplementary Materials
Surgical technique for TAVR explantation. Two Kocher clamps are applied to the nitinol stent frame then rotated inwards to involute the TAVR cage away from the aorta. Video available at: https://www.jtcvs.org/article/S2950-6050(24)00027-5/fulltext.
Surgical technique for MitraClip explantation. After removal of 2 MitraClips, significant anterior leaflet involvement necessitated mitral valve replacement. Video available at: https://www.jtcvs.org/article/S2950-6050(24)00027-5/fulltext.