Trends in Aortic Valve Reintervention: Incidence and Outcomes after Failed TAVI Among Medicare Patients

OBJECTIVE With the growing use of TAVI, data on TAVI failure and outcomes after reintervention remain limited. This study describes trends in reinterventions and associated outcomes, including mortality and heart failure (HF) hospitalization in elderly patients. METHODS Using the Medicare database, we identified 324,701 patients who underwent TAVI during 2013-2022. Trends in aortic valve reinterventions-including TAVI-in-TAVI and surgical explants-were analyzed using Joinpoint regression to report annual percent change (APC). A Cox proportional hazards model was used to estimate the association between the year of reintervention and the risk of outcomes as hazard ratios (HRs). RESULTS Between 2013 and 2022, 2,387 patients underwent aortic valve reintervention after TAVI (61.3% TAVI-in-TAVI and 38.7% surgical aortic valve replacement (SAVR)). The number of aortic valve reinterventions increased from 49 in 2013 to 505 in 2022 (APC:22.1%, p<0.001). There was an initial decline in the TAVI-in-TAVI incidence rate per 1,000 person-years (APC:-27.6% from 2013-2019), followed by a significant increase (APC:35.2% from 2019-2022). Meanwhile, the incidence rate remained unchanged for explant until 2017, after which it increased (APC:18.3%, p<0.001). After reintervention, 8.7% of patients died within 30 days, and 18.7% within one year. The adjusted risk of mortality (HR: 0.96 [95%CI: 0.93-0.99], p=0.01) and HF hospitalization (sHR: 0.87 [95%CI: 0.83-0.91], p<0.001) declined significantly over time. CONCLUSION Reinterventions, mainly surgical explants, have increased after TAVI. However, associated mortality and HF hospitalization have declined, reflecting an improvement in the management of failed TAVI in elderly patients. Further research into rising explant rates is warranted.