Sá Michel Pompeu, Ashwat Eishan, Jacquemyn Xander, Ahmad Danial, Brown James A, Serna-Gallegos Derek, Osho Asishana, Bloom Jordan P, Sultan Ibrahim
Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
Ann Cardiothorac Surg. 2025 Mar 31;14(2):85-97. doi: 10.21037/acs-2024-etavr-0075. Epub 2024 Oct 11.
Despite ever-growing adoption of transcatheter aortic valve replacement (TAVR) in younger healthier patients, a limited number of studies have described post-TAVR valve reinterventions such as surgical explantation known as "TAVR explant".
We performed a systematic review to characterize the current state of TAVR explant in patients with a failing transcatheter heart valve (THV) using data published by April 30, 2024 in compliance with the PRISMA and MOOSE reporting guidelines. The protocol was registered in PROSPERO (CRD42024529188).
Twenty-eight studies met the eligibility criteria. Almost all studies were non-randomized, observational, and retrospective. The incidence of TAVR explant ranged from 0.2% to 2.8% in patients with a mean age of 67.3-79.0 years, and women representing 25.0-47.1% of cases. The mean time between TAVR implant and explant was 17.0-674.9 days, with most studies reporting a mean time <365 days. Whereas the Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score at the time of the TAVR implant ranged between 2.6% and 7.7% (with only one study with score >5%), the STS-PROM score at the time of the TAVR explant ranged between 3.9% and 9.9% (with 17 studies with score >5%). Isolated surgical aortic valve replacement (SAVR) happened in 16.2-100% of cases, aortic root replacement was required in 2.6-41.2%, ascending aortic replacement was performed in 3.2-33.3% of cases. Mitral valve repair/replacement was necessary in 11.8-43.5% and tricuspid valve/repair replacement was done in 2.8-25.0%. Stroke rates were between 0.0% and 20.0% with most studies with rates above 4.0%. The 30-day death rate ranged from 4.8% to 50.0% with most studies with mortality rates higher than 10%. Observed-to-expected mortality ratio was higher than 1.0 in almost all the studies that reported this variable.
TAVR explant remains a rare event, but its clinical impact is non-negligible. Lifetime management strategies should be adopted in younger lower-risk patients when choosing THVs for the index TAVR.
尽管经导管主动脉瓣置换术（TAVR）在更年轻、健康的患者中应用越来越广泛，但仅有少数研究描述了TAVR术后瓣膜再次干预，如称为“TAVR瓣膜取出术”的外科取出术。
我们进行了一项系统评价，以利用截至2024年4月30日发表的数据，按照PRISMA和MOOSE报告指南，描述经导管心脏瓣膜（THV）功能衰竭患者中TAVR瓣膜取出术的现状。该方案已在PROSPERO（CRD42024529188）中注册。
28项研究符合纳入标准。几乎所有研究都是非随机、观察性和回顾性的。TAVR瓣膜取出术的发生率在平均年龄为67.3 - 79.0岁的患者中为0.2%至2.8%，女性占病例的25.0%至47.1%。TAVR植入与取出之间的平均时间为17.0 - 674.9天，大多数研究报告的平均时间<365天。TAVR植入时胸外科医师协会预测死亡率（STS - PROM）评分在2.6%至7.7%之间（只有一项研究评分>5%），而TAVR取出时STS - PROM评分在3.9%至9.9%之间（17项研究评分>5%）。16.2%至100%的病例进行了单纯外科主动脉瓣置换（SAVR），2.6%至41.2%需要进行主动脉根部置换，3.2%至33.3%的病例进行了升主动脉置换。二尖瓣修复/置换在11.8%至43.5%的病例中是必要的，三尖瓣修复/置换在2.8%至25.0%的病例中进行。卒中发生率在0.0%至20.0%之间，大多数研究发生率高于4.0%。30天死亡率在4.8%至50.0%之间，大多数研究死亡率高于10%。几乎所有报告该变量的研究中，观察到的与预期的死亡率之比均高于1.0。
TAVR瓣膜取出术仍然是一种罕见事件，但其临床影响不可忽视。在为初次TAVR选择THV时，对于年轻、低风险患者应采用终身管理策略。
