Annals of cardiothoracic surgery最新文献

The management of severe aortic stenosis (AS) has evolved significantly, with a shift toward shared decision-making regarding the choice of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). This shift necessitates careful consideration of long-term valve durability, as both TAVR and SAVR with bioprosthetic valves offer limited durability, potentially requiring reoperation later in life. While mechanical valves and the Ross procedure offer lifelong durability, patient preferences, including avoidance of anticoagulation, often dominate the discussion. This manuscript reviews the complex decision-making process in selecting the most appropriate valve for the first intervention, focusing on balancing the immediate benefits of a less invasive procedure with the long-term risks and the potential need for a second valve intervention. In the TAVR era, younger patients elect the least invasive treatment option with the shortest recovery. Age, anticoagulation tolerance, comorbidities, and aortic root anatomy influence valve choice, with particular attention to prosthesis-patient mismatch (PPM). Here, we emphasize that careful preoperative planning is essential to minimize PPM and optimize hemodynamics for the first valve, considering the possibility of future valve interventions. Furthermore, advanced imaging and simulation tools, such as computed tomography (CT) and artificial intelligence-based platforms, are now being utilized to predict the feasibility of redo interventions and guide the selection of the initial valve. The increasing prevalence of redo-TAVR and TAVR explantation underscores the importance of planning for a second valve at the time of the initial intervention. Simulation techniques can predict the anatomical feasibility of redo-TAVR, providing a safer framework for managing patients requiring subsequent valve replacements. Ultimately, heart teams must equip themselves with the tools and expertise necessary to ensure the durability of the first valve and readiness for future interventions, thereby improving patient outcomes over their lifetimes.

Background: Reoperations after transcatheter aortic valve replacement (TAVR) are increasingly reported with consistently poor outcomes. This study aimed to analyze clinical outcomes of TAVR explantation stratified by the original risk profile at the time of TAVR.

Methods: We reviewed our single institutional series of 110 consecutive patients who underwent TAVR explant between 2013 and 2024. This cohort was stratified into low-risk (n=35), intermediate-risk (n=35), and high/extreme-risk (n=40) categories based on the original risk profile.

Results: Low-risk patients began to appear in 2018. By 2021, the number of low/intermediate-risk patients surpassed that of the high/extreme-risk group. Balloon-expandable valves were predominantly used in the low-risk group, whereas chronic kidney disease was more prevalent in the other groups. The majority of patients in each group had either structural valve deterioration (SVD) and/or non-SVD as the primary failure mechanism, with endocarditis accounting for 20% or less. Cardiopulmonary bypass/aortic cross-clamp times were longest in the high-/extreme-risk group. Overall, 75 (68.2%) patients underwent a concomitant procedure during TAVR explant, most commonly an aortic (n=39; 52.0%) and a mitral procedure (n=29; 38.7%). The high/extreme-risk group had the highest rates of concomitant procedures. Operative mortality improved significantly over time, dropping from 27.3% in Era 1 (2013-2017) to 5.6% in Era 3 (2022-2024) (P=0.049). The operative and one-year mortality rates were 8.6%, 8.6%, and 7.5% (P=0.98), and 17.1%, 8.6%, and 17.5% (P=0.48) in the low-, intermediate-, and high-/extreme-risk group, respectively. Conversely, the observed-to-expected mortality ratio (O/E ratio) was highest in the low-risk group (2.8 vs. 1.0 vs. 0.8; P<0.001).

Conclusions: Low-risk patients are emerging as the predominant group requiring TAVR explant. Despite the procedural simplicity and lower-risk profile, the operative mortality was comparable to higher-risk groups, and the O/E ratio was significantly higher in the low-risk group. Thoughtful reconsideration of the TAVR-first approach may be warranted for this population.

Background: Transcatheter aortic valve replacement (TAVR) explant is an essential therapeutic option for late-stage biological valve failure (BVF) or prosthetic valve endocarditis (PVE) following TAVR, though poor outcomes have been reported. This study assesses TAVR explant outcomes at a high-volume Japanese center.

Methods: From October 2009 to December 2023, 10 TAVR explants were performed after 1,364 TAVR procedures at a leading Japanese high-volume center, and clinical outcomes were retrospectively analyzed. Data were drawn from a prospectively maintained database, assessing preoperative and intraoperative variables, as well as short- and long-term postoperative outcomes.

Results: Thirty-nine BVFs were observed during follow-up, and 16 (41.0%) redo-TAVRs were performed in the same timeframe. In the 10 (25.6%) TAVR explant cases, the median age of the patients was 79.5 years, with a predicted mortality for isolated surgical aortic valve replacement (SAVR) by Society of Thoracic Surgeons (STS) score of 4.5%. The primary indications for TAVR explant were PVE (40.0%) and structural valve deterioration (SVD) (30.0%). Concomitant procedures were necessary in 90% of cases, including aortic repair (40.0%) and mitral replacement or repair (30.0%). Aortic annulus reinforcement using autologous pericardium was performed in 30% of cases. The 30-day mortality rate was 20%, with 20% of cases requiring temporary mechanical circulatory support and postoperative continuous hemodiafiltration. In mid-term outcomes, the survival rate was 60% in 1 year and 40% in 3 years, respectively.

Conclusions: In this Japanese high-volume center experience, TAVR explants predominantly involved elderly patients and frequently required a concomitant procedure. The outcome was generally poor, comparable to those in Western countries. As the number of TAVR explants is expected to increase in Japan, knowledge-sharing within heart teams, including cardiac surgeons, is essential.

Background: Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical aortic valve replacement (SAVR) for severe symptomatic aortic stenosis (AS), including low-risk patients. We aimed to update a systematic review and conduct a meta-analysis of reconstructed time-to-event data from randomized control trials (RCTs) in low-/intermediate-risk patients.

Methods: Systematic searches were performed in PubMed, EMBASE, Cochrane CENTRAL, and specific websites up to November 2023, for RCTs. A meta-analysis was performed using the reconstructed time-to-event data from the provided Kaplan-Meier (KM) curves from the included RCTs. The primary outcome was all-cause mortality, and the secondary outcomes included a composite outcome (all-cause mortality and disabling stroke), and heart failure rehospitalization. Landmark analysis for endpoints beyond 1 year was performed. The study protocol was registered on PROSPERO (CRD42023487893).

Results: Six RCTs with a total of 7,389 patients were included. The survival was comparable between both groups [hazard ratio (HR), 1.03; 95% confidence interval (CI): 0.93-1.14; P=0.57]. The composite outcome and heart failure rehospitalization were comparable between the two groups. Lower mortality with TAVR was observed compared to SAVR before 1 year (HR, 0.82; 95% CI: 0.68-0.98; P=0.03), while TAVR was associated with higher risk of mortality beyond 1 year (HR, 1.13; 95% CI: 1.01-1.27; P=0.04). Similarly, the TAVR group was associated with lower risk for the composite endpoint and heart failure rehospitalization before 1 year, but with higher rates beyond 1 year.

Conclusions: Among low- to intermediate-risk patients, TAVR was found to be associated with favorable outcomes in the short-term (0-1 year). However, our landmark analysis demonstrated TAVR to be associated with poorer outcomes beyond 1 year.

The rise of transcatheter aortic valve replacement (TAVR) over the past two decades has substantially changed the lifetime management of patients with aortic valve disease. As the indications for TAVR expand to include younger and lower-risk patients, the proportion of patients who subsequently require reintervention for failed transcatheter heart valves (THVs) will increase. The two primary options for reintervention are redo TAVR and TAVR explant followed by surgical aortic valve replacement (SAVR). The indications for redo TAVR in the short term include emergency "bailout" procedures due to malpositioning, embolization, or long-term device failure due to paravalvular leak (PVL) or valvular degeneration. However, redo TAVR is not suitable for all patients. Those with prohibitive coronary anatomy, multivalvular involvement, severe patient-prosthetic mismatch, or endocarditis should be referred for TAVR explant, which is a comparatively higher-risk procedure. Redo TAVR has generally been associated with low mortality and complication rates, with key procedural considerations being valve selection [e.g., sizing, balloon-expandable valve (BEV) vs. self-expandable valve (SEV)], access, and coronary protection. TAVR explant poses numerous technical challenges, including concomitant ascending aorta or aortic root replacement, mitral valve involvement, or adhesions to the coronary ostia. Compared to redo TAVR, TAVR explant is associated with higher rates of short-term mortality and periprocedural complications. The 30-day mortality rates of TAVR explant approach 20%, and 1-year mortality rates range from 20% to 30%, with significantly greater risk associated with concomitant procedures. The data on both redo TAVR and TAVR explant are limited to observational cohorts without long-term follow-up. Given that patient populations and indications for redo TAVR and TAVR explant are vastly different, direct comparisons of outcomes between these two groups should be avoided. Nonetheless, multidisciplinary Heart Team collaboration remains imperative to advancing our knowledge of redo TAVR or TAVR explant procedures and the careful lifetime management of patients with aortic valve disease.