TAVR Explantation: A Necessary Skill Set in the Contemporary Cardiac Surgery's Armamentarium

With the recent approval for transcatheter aortic valve replacement (TAVR) across all risk profiles, reintervention is likely to become common practice. As surgeons treat younger, fitter patients with longer life expectancies, complications such as thrombosis, endocarditis, non-structural valve deterioration and, of course, structural valve deterioration will warrant reintervention, which may require a high-risk surgical procedure in some cases. This video presents a case of a TAVR explantation due to nonstructural valve deterioration and severe aortic regurgitation due to perivalvular leak in a sixty-five-year-old man. The authors aim to emphasize both the technical aspects of the surgery and the importance of patient individualization for each procedure.



The Patient

The patient is a sixty-five-year-old male without allergies, independent in daily activities, and with a medical history of HTA, COPD (former smoker of three packs per day), morbid obesity (BMI over 40), and ischemic heart disease with a chronic total occlusion (CTO) of the right coronary artery (RCA), which was untreated in his native country. He visited the authors’ center for two to three months of minimal effort dyspnea (NYHA III), angina, orthopnea, and lower limb oedema. 

Diagnostic studies revealed severe aortic regurgitation with severe LV dysfunction (LVEF less than 30 percent). The heart team discussion ended with the decision to perform TAVR. Immediately after the implantation, the patient developed AVB, LBHB, and ST elevation in anterior leads. Angiography revealed an acute thrombotic occlusion of the mid-LAD and an angioplasty with a stent was performed successfully. Follow up echocardiography showed a severe aortic regurgitation with a severe posterior perivalvular leak and LVEF of 35-40 percent. As the patient developed severe symptoms, he was scheduled for TAVR explantation and SAVR, as percutaneous closure of leak and valve-in-valve was technically difficult.

The Surgery

The procedure was performed under general anesthesia and conventional monitoring, as well as transesophageal echocardiography (TEE). A median sternotomy was performed, and cardiopulmonary bypass was started with atriocaval and aortic cannulation. A hemi-or mini sternotomy, or even other minimal invasive approaches, may be used if no further procedures are planned. Nevertheless, the possibility of aortic root damage and/or replacement, coronary arteries manipulation, and concomitant mitral valve surgery—if the anterior leaflet is damaged—tip the balance in favor of a conventional approach for good exposure and minimizing complications. In this case, a right coronary artery bypass was needed.

The aorta must be examined beforehand, especially in self-expandable prostheses, in which their height can protrude into the ascending aorta. Enough space for root and cardioplegia cannula and aortic clamp must be assured. After clamping the aorta, retroplegia was delivered due to severe aortic regurgitation and low feasibility of direct coronary artery ostia cardioplegia delivery. The left vent was inserted through the right superior pulmonary vein. An oblique aortotomy in a “J” shape was then performed and the prosthesis was identified. It was extended to the level of the aortic annuli at the noncoronary sinus because the native valve and prosthesis were severely adhered to the aortic wall. 

With self-expandable prostheses, a taller aortotomy may be required, although care must be taken since it can make SAVR more difficult. Inspection of the prosthesis was completed and a dissection plane between the aortic intimae and the prosthesis was found. Careful dissection with a scalpel and spatula was then completed. The nitinol frame stent of the self-expandable prosthesis can be compressed or collapsed on its own with ice-cold saline irrigation (sometimes cardioplegia temperature can do the job as well). Rewarming activated nitinol and brought it back to its expanded position. Repeated irrigation was needed. 

Next, with the balloon expandable prosthesis, two Kocher clamps were used for maneuvering and deforming the frame to apply gentle countertraction and find the correct dissection plane. A thick silk or a 3-0 Prolene suture was woven around every other stent cell and then snared down with a tourniquet to withdraw or overpower its outward radial force. This technique is also applied to self-expandable prostheses because it is safer and more efficient. These techniques ease prosthesis mobilization, improve ,and enable dissection further down to the nadir of the prosthesis.

After explantation, native valve removal, annular debridement, and decalcification are of paramount importance to avoid emboli, paravalvular leaks, and to ensure a good size prosthesis implantation. This may be difficult when the tissues are heavily calcified and compressed.

SAVR with a 27 mm tissue prosthesis was performed in the standard fashion and an RCA bypass with a saphenous vein graft was used. Close attention was paid to the extended aortotomy closure to avoid postoperative bleeding.

The patient was weaned off CPB and TEE showed good biventricular motion and a normally functioning tissue valve. The patient was extubated six hours later. He was transferred to the floor on postoperative day two and discharged on postoperative day 10. He developed postoperative atrial fibrillation and atrial flutter that did not reverse to sinus rhythm with medical therapy. He was scheduled for an ablation two months later. He is currently asymptomatic (NYHA I) in sinus rhythm and the latest TTE shows a well-positioned prosthesis with correct functioning and gradients and a LVEF of 45 percent.

TAVR explantation may be a high-risk procedure that will likely become common in the field. Anatomic and technical factors of previously failed TAVR can make it difficult to perform valve-in-valve or percutaneous leak closure procedures. Careful preoperative planning is needed. Surgical TAVR explantation can end in full aortic root replacement depending on post-TAVR removal structural defects. As TAVR indications expand, it is surgeons’ obligation to promote rationality and think ahead of time, as many young, low risk patients will eventually need some valve reintervention down the road.

References

1. Tang GHL, Zaid S, Kleiman NS, Goel SS, Fukuhara S, Marin-Cuartas M, et al. Explant vs Redo-TAVR after transcatheter valve failure. JACC: Cardiovascular Interventions. 2023;16(8):927–41.
2. Bapat VN, Zaid S, Fukuhara S, Saha S, Vitanova K, Kiefer P, et al. Surgical explantation after TAVR failure. JACC: Cardiovascular Interventions. 2021;14(18):1978–91.
3. Fukuhara S, Brescia AA, Shiomi S, Rosati CM, Yang B, Kim KM, et al. Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications. The Journal of Thoracic and Cardiovascular Surgery. 2021;162(2).
4. Valdis M, Hage F, Diamantouros P, Bagur R, Teefy P, Chu MWA. Snaring technique for explantation of transcatheter aortic valve bioprosthesis. Ann Cardiothorac Surg 2020;9(6):534-536.
5. Mangi AA, Ramchandani M, Reardon M. Surgical removal and replacement of chronically implanted transcatheter aortic prostheses: How I teach it. The Annals of Thoracic Surgery. 2018;105(1):12–4.
6. Reul RM, Tom S, Tully A, Grubb KJ. Lessons from failures: Explant-TAVR analysis provides insights into a growing patient population. The Annals of Thoracic Surgery. 2023;116(5):942–3.

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