Nonaortic Valve Cardiac Surgery After Transcatheter Aortic Valve Replacement

Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), the frequency and outcomes of nonaortic valve cardiac surgery after TAVR are unknown.

Nonaortic valve surgery after TAVR from 2011 to 2019 was queried using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. A total of 666 patients, including 47 (7.1%) unplanned TAVR explants and 3 (0.5%) aborted procedures during nonaortic valve procedures, were identified.

These 666 procedures were performed by 459 surgeons (median, 1.0 case per surgeon) from 308 centers (median, 1.0 case per center), representing 29% of STS Database participants. The case number increased over time from 4 in 2011 to 204 in 2019, largely attributable to coronary artery bypass grafting (CABG) (n = 283; 42.5%) and mitral valve (n = 258; 38.7%) procedures. The median age patients of was 75.0 years, and 51.4% had undergone previous cardiac surgical procedures. The 30-day mortality of the entire cohort was 17.0%. Subgroups with particularly high mortality included patients with robot-assisted mitral surgery (n = 5/12; 41.7%), an unplanned TAVR explant (n = 19/47; 40.4%), open atrial transcatheter mitral valve replacement (n = 10/33; 30.3%), and aortic repair (n = 24/79; 29.8%). Among 390 patients with available STS predicted risk of mortality, the 30-day mortality in patients with isolated CABG, patients with isolated mitral repair or replacement, and in the entire group was 8.4% (n = 19/225), 13.5% (n = 21/155), and 10.8% (n = 42/390) with corresponding observed-to-expected mortality (O/E) ratios of 1.8, 1.8, and 1.7, respectively.

Nonaortic valve operation after TAVR was associated with a high mortality and O/E ratio. The TAVR team must be mindful of a "lifetime management" strategy, including assessment of concurrent diseases during TAVR candidate selection.