Impact of TAVR Failure Mechanism on Outcomes After Reintervention: From the EXPLANTORREDO-TAVR Registry

BACKGROUND: As transcatheter aortic valve replacement (TAVR) expands to patients with longer life expectancy, the impact of failure mechanisms on outcomes of TAVR-explant and redo-TAVR remains uncertain. We sought to evaluate outcomes of TAVR reintervention based on the failure mechanism of the index transcatheter aortic valve. METHODS: From 2009 to 2022, 553 patients from 29 centers in the EXPLANTORREDO-TAVR registry underwent TAVR-explant or redo-TAVR for transcatheter aortic valve failure. Patients with endocarditis were excluded. Patients with structural valve deterioration (SVD, N=224 [64.9%]) were compared with those with nonstructural valve dysfunction (NSVD, N=121 [35.1%]), comprising paravalvular leak (86.0%) and prosthesis-patient mismatch (14.0%). Outcomes were assessed at 30 days and 1 year. RESULTS: Mean age was 75.6±9.3 years, with 42% women. There were no differences in reintervention type between groups (redo-TAVR in 58.0% SVD versus 49.6% NSVD; TAVR-explant: 42.0% versus 50.4%; P=0.14). Compared with NSVD, SVD was the predominant mode of failure in balloon-expandable valves (50.7% versus 24.8%; P<0.001), had a longer time to reintervention (50.7 versus 5.5 months; P<0.001), and favored non-balloon-expandable valves at redo-TAVR (56.9% versus 33.3%; P=0.003). Mortality at 30 days and 1 year did not differ significantly between SVD and NSVD for either redo-TAVR (30 days: 3.2% versus 1.7%, P=1.00; 1 year: 18.0% versus 12.0%; P=0.47) or TAVR-explant (30 days: 16.3% versus 12.1%, P=0.63; 1 year: 40.0% versus 29.5%; P=0.39). There were also no differences in risk-adjusted 3-year cumulative mortality between groups (redo-TAVR: HR, 1.30 [95% CI, 0.68-2.46], P=0.43 [ref=NSVD]; TAVR-explant: HR, 1.24 [95% CI, 0.64-2.41]; P=0.53). CONCLUSIONS: SVD and NSVD failures had distinct valve types and reintervention timing, with SVD having a longer time to TAVR reintervention, but the failure mechanism did not impact reintervention type or clinical outcomes.