Long-term Survival Better With TAVI Explant vs Redo: Medicare Data

NEW YORK, NY—Among the small but steadily increasing patient population requiring reinterventions after TAVI in the United States, surgical explant is associated with better long-term survival compared with redo transcatheter procedures, according to new Medicare data.

The overall rate of reinterventions in more than 4,000 patients who underwent TAVI between November 2011 and September 2024 was 2.3%. While 30-day mortality rates were higher for TAVI explant than for redo TAVI (15.3% vs 4.9%), unadjusted survival curves over 6 years showed a significant survival advantage with explantation starting at 1.8 years, and this held true even when excluding patients with endocarditis (P < 0.001 for both).

The findings should paint a more optimistic picture for surgeons hesitant to take on these patients in light of prior evidence showing dire outcomes, say researchers.

“It is a really encouraging safety net for younger patients who are choosing to have a TAVR,” said Shinichi Fukuhara, MD (University of Michigan, Ann Arbor), who presented the results Wednesday at NY Valves 2025.

To TCTMD, he said cardiac surgery societies now have a “duty [to] show that we’re really improving outcomes,” but added that cardiologists should do more to educate their patients considering TAVI about the possibility of reintervention down the line. “We have performed more than 160 TAVR explants at the University Michigan now, [and] everybody says: ‘Nobody told me anything about the open-heart surgery after TAVR.’”

Cardiac surgeon Michael Borger, MD (University of Leipzig, Germany), who discussed the findings during the session, said more work should be done looking into which patients might be at greater risk for reinterventions, but that it’s clear “these are patients that, for whatever reason, have some sort of hostile situation towards TAVR.”

That may be the result of anatomy, such as the presence of a bicuspid valve, but the patients’ experience has already shown that TAVI is not effective for them, he said. “Therefore, I think it’s not terribly surprising that if we add more hostility to an already hostile situation, we’re not going have good long-term results,” said Borger, referring to redo procedures.

Medicare Data

The analysis included 4,443 Medicare beneficiaries who underwent TAVI and subsequently received redo TAVI (n = 2,553) or TAVI explant (n = 1,890). Compared with explantation, redo TAVI patients were older, more often female, frailer, and had more comorbidities. Endocarditis was more likely in the TAVI explant group (27.6% vs 2.4%; P < 0.001). 

Presentation NY Valves 2025

TAVR Reintervention Strategies: Unveiling Trends and Outcomes of Redo TAVR and TAVR Explant

The time to reintervention was significantly shorter for patients who had the device taken out compared to having redo TAVI (roughly 3 years versus 12 months). This is likely because redo TAVI cases are “mostly degenerations,” said Fukuhara, while TAVI explants are caused by a mix of endocarditis, paravalvular leak, as well as degeneration.

In a propensity score-matched analysis of 1,584 patients in each group, survival was higher in the TAVI explant arm than in redo TAVI, with the curves crossing at 1.8 years (P < 0.001). Also, the risk of TAVI explant dropped below that of redo TAVI at 7 months (HR 0.86; 95% CI 0.77-0.97).

When patients were stratified by age, explantation held a significant survival advantage over redo TAVI in those 65-70 years old (beginning at 1.3 years; P = 0.011), but the survival benefit wasn’t seen in those aged 70-80 or greater than 80 years.

Lastly, compared with redo TAVI, fewer patients who underwent TAVI explantation needed a second reintervention (6.2% vs 31.2%; P = 0.01).

It is a really encouraging safety net for younger patients who are choosing to have a TAVR. Shinichi Fukuhara

Fukuhara acknowledged the current “perception that TAVR explant is associated with really dismal outcomes,” and even admitted to being surprised by their survival findings “being a lot better than I thought.” He stressed, however, that explantation and redo TAVI are not “mutually exclusive” procedures. “We should rather wisely choose what’s best for patients based on the patient characteristics.”

Timeliness is also imperative, Fukuhara said. “Patients who did not do well after TAVR explant are typically [people] who waited and waited, [and who] explored some other nonsurgical options, and ended up being in renal failure and heart failure. Those are the people who didn’t do well. So timely TAVR explant procedures, I believe, will yield excellent outcomes.”

Biases but Still Relevant

Commenting on the study for TCTMD, Michael Bowdish, MD (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA), said it “adds to the data we should consider when approaching patients who are of acceptable surgical risk and have had a previous TAVR, based on their perceived life expectancy. If they are reasonable operative candidates, TAVR explant and surgical AVR may be appropriate.”

While the study is limited by factors and biases that affect all claims-based studies, including lack of data on why patients needed a reintervention, “an RCT in this area would be challenging,” Bowdish continued. “But this study does add to the evidence suggesting that such a trial would be beneficial as we continue to understand how best to guide patients through the many options for the long-term treatment of aortic valve disease.”

If they are reasonable operative candidates, TAVR explant and surgical AVR may be appropriate. Michael Bowdish

Similarly, Tsuyoshi Kaneko, MD (Washington University School of Medicine in St. Louis, MO), who was not involved in the study, told TCTMD the analysis is limited by a “heavy” selection bias in that many patients who are not expected to survive surgical intervention are excluded.

“They probably go for transcatheter therapies, and they might survive that, but they’ll die in a year, which is their natural history,” he said. “I think there’s a lot of those patients that are included, and claiming the superiority of surgery in that population probably is not the best way to analyze this data.”

Kaneko also pointed to the “steep” mortality curve that’s evident immediately following TAVI explant. “It just shows you how risky these procedures are,” he said. “It’s not a benign procedure, but I think what that curve shows is that, for TAVR explant specifically, if they can survive that initial curve in that first 30, 60 days, then afterwards . . . they do okay.”

Given the early outcomes with redo procedures, these data also show “TAV-in-TAV is a very safe therapy,” he said.