Lee Grace S, Tang Gilbert, Zaid Syed, Tam Derrick Y
Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada.
Mount Sinai Health System, Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Ann Cardiothorac Surg. 2025 Mar 31;14(2):98-111. doi: 10.21037/acs-2024-etavr-0149. Epub 2025 Mar 4.
The rise of transcatheter aortic valve replacement (TAVR) over the past two decades has substantially changed the lifetime management of patients with aortic valve disease. As the indications for TAVR expand to include younger and lower-risk patients, the proportion of patients who subsequently require reintervention for failed transcatheter heart valves (THVs) will increase. The two primary options for reintervention are redo TAVR and TAVR explant followed by surgical aortic valve replacement (SAVR). The indications for redo TAVR in the short term include emergency "bailout" procedures due to malpositioning, embolization, or long-term device failure due to paravalvular leak (PVL) or valvular degeneration. However, redo TAVR is not suitable for all patients. Those with prohibitive coronary anatomy, multivalvular involvement, severe patient-prosthetic mismatch, or endocarditis should be referred for TAVR explant, which is a comparatively higher-risk procedure. Redo TAVR has generally been associated with low mortality and complication rates, with key procedural considerations being valve selection [e.g., sizing, balloon-expandable valve (BEV) self-expandable valve (SEV)], access, and coronary protection. TAVR explant poses numerous technical challenges, including concomitant ascending aorta or aortic root replacement, mitral valve involvement, or adhesions to the coronary ostia. Compared to redo TAVR, TAVR explant is associated with higher rates of short-term mortality and periprocedural complications. The 30-day mortality rates of TAVR explant approach 20%, and 1-year mortality rates range from 20% to 30%, with significantly greater risk associated with concomitant procedures. The data on both redo TAVR and TAVR explant are limited to observational cohorts without long-term follow-up. Given that patient populations and indications for redo TAVR and TAVR explant are vastly different, direct comparisons of outcomes between these two groups should be avoided. Nonetheless, multidisciplinary Heart Team collaboration remains imperative to advancing our knowledge of redo TAVR or TAVR explant procedures and the careful lifetime management of patients with aortic valve disease.
在过去二十年中，经导管主动脉瓣置换术（TAVR）的兴起极大地改变了主动脉瓣疾病患者的终身管理方式。随着TAVR的适应症扩大到包括更年轻和风险更低的患者，随后需要对失败的经导管心脏瓣膜（THV）进行再次干预的患者比例将会增加。再次干预的两个主要选择是再次TAVR和取出TAVR后进行外科主动脉瓣置换术（SAVR）。短期内再次TAVR的适应症包括因瓣膜位置不当、栓塞或因瓣周漏（PVL）或瓣膜退变导致的长期器械故障而进行的紧急“补救”手术。然而，再次TAVR并不适用于所有患者。那些冠状动脉解剖结构复杂、多瓣膜受累、严重的患者-人工瓣膜不匹配或患有心内膜炎的患者应转诊进行TAVR取出术，这是一个风险相对较高的手术。再次TAVR一般与低死亡率和并发症发生率相关，关键的手术考虑因素包括瓣膜选择[例如尺寸、球囊扩张瓣膜（BEV）、自膨胀瓣膜（SEV）]、入路和冠状动脉保护。取出TAVR带来了许多技术挑战，包括同期升主动脉或主动脉根部置换、二尖瓣受累或与冠状动脉开口粘连。与再次TAVR相比，取出TAVR与更高的短期死亡率和围手术期并发症发生率相关。取出TAVR的30天死亡率接近20%，1年死亡率在20%至30%之间，同期手术相关风险显著更高。关于再次TAVR和取出TAVR的数据都仅限于无长期随访的观察性队列。鉴于再次TAVR和取出TAVR的患者群体和适应症差异很大，应避免对这两组的结果进行直接比较。尽管如此，多学科心脏团队合作对于增进我们对再次TAVR或取出TAVR手术的了解以及对主动脉瓣疾病患者进行谨慎的终身管理仍然至关重要。
