Operating the Inoperable: Reoperations after Transcatheter Aortic Valve Replacement

Objectives: There are a growing number of patients after transcatheter aortic valve replacement (TAVR) who are referred to cardiac surgery units with various indications for ‘redo’ cardiac surgery. In these high-risk patients who have been previously considered to be ‘inoperable’ indications for surgery often are controversially discussed. We report our experience with cardiac surgery after TAVR.

Methods: A review of our institutional database from September 2015 to August 2018 revealed five patients who underwent cardiac surgical procedures after previous TAVR. Data were retrospectively reviewed and analyzed. They were presented as medians (25th - 75th percentiles), absolute numbers and percentages.

Results: The median age was 76 years (69–82 years), 80.0% of the patients were male. The median EuroSCORE II was 34.7% (30.2–63.9%). Indications for surgery were tricuspid valve regurgitation in two patients, combined mitral and tricuspid valve regurgitation in one patient and prosthetic-valve endocarditis in two patients. Surgical procedures were minimally invasive tricuspid valve surgery in the beating heart technique (n = 2), replacement of the TAVR- prostheses by biological heart valves in two patients diagnosed with prosthetic valve endocarditis and mitral valve replacement and tricuspid valve repair through a median sternotomy. The median interval between TAVR and ‘reoperation’ was 560 days (130–1,226 days). The median duration of surgery was 247 min (188–396 min). Main complications were low output syndrome (n = 3), re-explorative surgery (n = 3), nosocomial pneumonia (n = 5), and renal failure (n = 3). One patient required ECLS support. We did not observe any adverse cerebrovascular events. The median duration of postoperative mechanical ventilation was 152 hours (60–552 hours) and the median duration of ICU stay was 20 days (10–38 days). The 30-day mortality was 20.0% (n = 1).

Conclusions: Cardiac surgical procedures in patients after TAVR are increasingly required. According to our experience, these operations are technically feasible; however, they are associated with a substantial risk. The operative trauma should be held as low as possible, i.e., by minimal invasive access or beating heart techniques. Therefore, indications have to be thoroughly evaluated, even in cases of ultima ratio therapy.