Clinical outcomes of TAVR explant stratified by original risk profile: insights from 110 TAVR explants

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.