Volume–outcome relationship of mortality following surgical explant of transcatheter aortic valve replacements

OBJECTIVE: To evaluate the relationship between hospital volume of transcatheter aortic valve replacement (TAVR) explants and postoperative mortality. METHODS: The Center for Medicare & Medicaid Services was queried from 2016 to 2024 for patients who underwent TAVR explant. The study period was divided into 2 eras: early (2016-2021) and recent (2022-2024). Hospitals were classified grouped as low volume or high volume. Both 30-day and 1-year mortality were compared, and multivariable analysis was performed. RESULTS: We identified a total of 123 TAVR explants during the study period. Of the 375 hospitals that performed at least 1 TAVR explant, 235 (63%) performed fewer than 3 explants. Postoperative mortality was 13.3% at 30 days and 18.3% at 1 year. Thirty-day mortality was higher in low-volume hospitals compared to high-volume hospitals in the early era (17% vs 9.68%; P = .029), but not in the recent era (11.0% vs 13.4%; P = .409). At low-volume hospitals, both 30-day and 1-year mortality were higher following concomitant TAVR explant compared to isolated TAVR explant (19.9% vs 9.3% [P < .001] and 25.4% vs 13.6% [P < .001], respectively), but not in high-volume hospitals (14% vs 8.78% [P = .148] and 18.3% vs 15.5% [P = .518], respectively). On multivariable analysis, high-volume hospital status was associated with lower mortality for the early era (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25-0.95), but not for the recent era (OR, 1.30; 95% CI, 0.71-2.38) or the total cohort (OR, 0.80; 95% CI, 0.51-1.24). CONCLUSIONS: While a hospital volume-outcome relationship to TAVR explant mortality existed in the early era, recent data suggest no volume-outcome relationship. With the lack of a volume-outcome relationship, TAVR explant will become a fundamental cardiac surgical procedure. High-risk concomitant surgery may benefit from high-volume hospital management.