TAVR Reinterventions: Redo vs. Surgical Removal – Trends and Clinical Insights
TAVR Reinterventions: Redo vs. Surgical Removal – Trends and Clinical Insights
Source: JAMA Cardiology, Sept 24, 2025.
1. Levels of Indication
• Transcatheter Aortic Valve Replacement (TAVR) expanded significantly after the PARTNER-3 and Evolut Low Risk trials in 2019, which demonstrated safety and efficacy even in low-risk patients.
• However, guidelines do not assign Class I recommendation to TAVR in all low-risk groups:
• ACC/AHA 2020:
• Class I: TAVR for patients at high surgical risk.
• Age 65–80 years: Either TAVR or SAVR is reasonable
• <65 years with long life expectancy: SAVR remains the preferred option.
• ESC/EACTS 2021:
• Favors TAVI ≥70 years or high-risk patients if transfemoral access is feasible. For <70 years and low risk, SAVR is recommended.
• Bottom line: Since 2019, robust evidence has supported TAVR across risk strata, but TAVR is not a universal Class I option for all low-risk patients.
2. Study Overview
• Data: More than 410,000 patients undergoing TAVR (Jan 2012 – Jun 2024).
• Overall reintervention rate: 0.91% (redo TAVR or surgical removal).
• Breakdown:
• Redo TAVR (valve-in-valve): 63.8%
• Surgical removal with SAVR (open heart surgery): 36.2%
3. Clinical Characteristics
• Redo TAVR patients: 86.8% had heart failure.
• Surgical removal group:
• 16.1% underwent CABG.
• 25% had concomitant mitral valve surgery.
• 14.9% had thoracic aortic surgery.
• Timing: Most redo TAVRs occurred within ≤3 months of the index procedure, suggesting early technical failure (e.g., paravalvular leak, prosthesis–patient mismatch).
4. Trends Over Time
• TAVR reinterventions: Increased from 0.17% in 2019 → 0.28% in 2023.
Findings in the surgical valve replacement (SAVR) cohort (~300,000 patients):
• After (SAVR), 1.68% of patients later received a TAVR inside the surgical valve (valve-in-valve TAVR).
• 1.4% of patients required a second surgical valve replacement (redo SAVR).
• The overall rate of reinterventions after SAVR increased over time: from 0.24% in 2014 to 0.73% in 2023.
• This increase was driven mainly by the growing use of valve-in-valve TAVR, while redo SAVR procedures have declined.
• Redo SAVR is declining; the increase is entirely driven by valve-in-valve TAVR.
5. Redo TAVR vs. Surgical Removal
Redo TAVR (Valve-in-Valve procedure)
• Definition: Valve-in-Valve TAVR = implanting a new transcatheter valve inside a previously implanted valve (surgical or transcatheter), not the native valve.
• Indication: Valve-in-Valve TAVR is indicated for degenerated bioprosthetic valves; mechanical valves are not suitable for this procedure.
• Advantages:
• Less invasive, lower perioperative risk.
• Shorter recovery; often preferred in elderly or high-risk patients.
• Limitations:
• Higher residual gradients if the prior valve was small.
• Not feasible in the presence of infection or unfavorable anatomy.
Surgical Removal with SAVR (open heart surgery)
• Indications:
• Prosthetic valve infection (endocarditis).
• Severe calcification or degeneration preventing stable anchoring of a new valve.
• Anatomical limitations (e.g., high risk of coronary obstruction, device malposition).
• Major complications (device migration, aortic root injury).
• Limitations:
• More technically complex, associated with higher operative risk.
• Requires advanced surgical expertise and specialized centers.
6. Clinical Message
• Redo TAVR should be the preferred reintervention when technically feasible, particularly in elderly or high-risk patients.
• Surgical removal with SAVR is required when valve infection, anatomic limitations, or severe degeneration make redo TAVR unsafe.
• Reinterventions remain rare (<1%) but are increasing as younger, lower-risk patients undergo TAVR.
• Highlights the importance of lifetime management strategies for aortic stenosis, with careful Heart Team decision-making at the index procedure.
7. Key Takeaways
1. TAVR has strong trial evidence across risk levels, but is not Class I for all low-risk patients.
2. Overall reintervention rate remains low (0.91%) but is increasing with broader TAVR use.
3. Redo TAVR is usually favored: less invasive, safer in most cases.
4. Surgical removal with SAVR is necessary in cases of infection, anatomical challenges, or major complications.
5. Personalized Heart Team planning is critical to optimize long-term outcomes and durability strategies.
