Aortic Valve Surgery: What Do Our Patients Need to Know?
Richard E. Clark Memorial Paper for Adult Cardiac Surgery: Increased Risk of Surgical Aortic Valve Replacement After Prior Transcatheter Versus Surgical Aortic Valve Replacement with Concomitant Valve Disease
Saturday, January 25, 2025
4:30pm – 4:38pm PT
Location: 403B
R. Hawkins1, B. Hamilton1, D. Sukul1, G. Deeb2, G. Ailawadi3, S. Fukuhara1 1University of Michigan, Ann Arbor, Michigan 2University of Michigan, Michigan Medicine, Ann Arbor, Michigan 3The University of Michigan Cardiovascular Center, Ann Arbor, Michigan
Disclosure(s):
Robert B. Hawkins, MD, MSc: Medtronic: Speaker/Honoraria (includes speakers bureau, symposia, and expert witness) (Ongoing)
Purpose: Reoperation after transcatheter aortic valve replacement (TAVR) has increased risk compared with prior surgical aortic valve replacement (SAVR). The etiology of this increased risk is poorly understood, and this study aims to clarify the impact of concomitant mitral and tricuspid valve disease on associated risk for TAVR explant. Methods: Patients undergoing aortic valve replacement after SAVR or TAVR were extracted from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). Patient undergoing concomitant aortic replacement or mitral and tricuspid procedures were included. Patients undergoing planned coronary bypass, circulatory arrest, or other complex cardiac procedures were excluded. Patients were stratified by TAVR explant versus redo-SAVR. The primary outcome was operative mortality. Risk adjustment was performed using multivariable logistic regression. Interaction terms were utilized to evaluate differential risk of concomitant valve disease for TAVR explant versus redo-SAVR. Results: Of 24,097 redo aortic valve replacement patients, 877 (3.6%) underwent TAVR explant. Prior TAVR patients had higher overall rates of concomitant severe valve disease (17% vs 14%, p< 0.001), including severe mitral regurgitation (13.1% vs 8.8%, p< 0.001), but no difference in severe mitral stenosis (1.3% vs 1.8%, p=0.218) or severe tricuspid regurgitation (5.3% vs 5.4%, p=0.842). Patients with severe concomitant valve disease had higher mortality for both TAVR explant (19.3% vs 11.9%, p=0.016) and redo-SAVR (12.9% vs 8.5%, p< 0.001). The increased mortality rates can be seen in the Figure. In this complex patient cohort, TAVR explant was associated with 1.3-fold increase in the odds of mortality, while the three different valve pathologies increase risk of mortality between 1.2 and 2.0 times (Table). Addition of interaction terms between TAVR explant and severe valve pathologies were non-significant (p>0.05) suggesting no differential increased risk for severe valve disease with prior SAVR versus TAVR. Conclusion: TAVR explant cases have a higher burden of concomitant valve disease and are at extreme risk for mortality (24%-46%). Heart teams should consider these findings when discussing initial procedure choices for patients with multi-valve disease, while prompt surgical referral for dysfunctional TAVR valves is warranted to potentially avoid risks associated with multi-valve disease.
Identify the source of the funding for this research project: The Family of Harpreet and Sangeeta Ahluwalia Fund