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Cardiac Operations After Transcatheter Aortic Valve Replacement
James J Yun1, Osama Abou Saleh1, Jin Woo Chung1
1Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
Insights
Cardiac operations after transcatheter aortic valve replacement (TAVR) are rising, with shorter intervals between procedures. These complex reoperations carry significant risks and should be considered in TAVR patient selection.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Medical Device Technology
Background:
- Transcatheter aortic valve replacement (TAVR) is a common procedure for severe aortic stenosis.
- Limited data exists on the characteristics and outcomes of subsequent cardiac operations post-TAVR.
- This study examines a single-center experience with cardiac surgery following TAVR.
Purpose of the Study:
- To investigate patient demographics, timing, and indications for cardiac operations after TAVR.
- To evaluate the outcomes of these post-TAVR cardiac surgeries.
- To inform clinical decision-making regarding TAVR in patients with complex cardiac conditions.
Main Methods:
- Retrospective analysis of 59 patients undergoing cardiac operations after TAVR between January 2012 and July 2020.
- Inclusion of patient characteristics, operative details, and Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores.
- Analysis of indications for surgery, TAVR valve explantation, and operative outcomes.
Main Results:
- Cardiac operations post-TAVR increased significantly, with a decreasing interval between procedures.
- Most operations were complex reoperations (68% with no calculable STS-PROM), with TAVR valve stenosis/regurgitation as the primary indication (58%).
- Operative mortality was 8.5%, with notable rates of postoperative stroke (3.4%) and dialysis (10%).
Conclusions:
- Cardiac operations after TAVR are increasingly common and performed sooner after the initial procedure.
- These are typically high-risk reoperations, with isolated aortic valve replacement being infrequent.
- Findings necessitate careful consideration of TAVR in patients with multiple cardiac pathologies or low-to-intermediate surgical risk.
Background:
Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience.
Methods:
From January 2012 to July 2020, 59 patients (median age, 70 years) underwent cardiac operations after TAVR, 38 (64%) of which were performed in other centers. The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at the time of prior TAVRs and at applicable index cardiac operations.
Results:
From 2012 to 2018, fewer than 10 operations were performed after TAVR, but 18 were performed in 2019. The interval between prior TAVR and cardiac surgery decreased exponentially from 7 years to less than 1 year over the experience. In applicable cases (19 of 59 operations [32%]), the median STS-PROM was 5.5% (15th-85th percentiles, 3.1%-25%), and 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical aortic valve replacements. TAVR valve stenosis/regurgitation (34 [58%]) was the leading indication, followed by paravalvular leak in 14 (24%) and endocarditis in 10 (17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative death occurred in 5 (8.5%), postoperative stroke in 2 (3.4%), and postoperative dialysis in 6 (10%).
Conclusions:
Cardiac operations after TAVR are increasing, and the interval between TAVR and operation is decreasing. Most cardiac operations are complex, high-risk reoperations, and isolated aortic valve replacement is rare. These findings should be considered when TAVR is selected for low- to intermediate-risk patients, particularly with multiple cardiac pathologies not addressed by TAVR.
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