key: cord-0996827-ib8xm4ba
authors: Reich, Heidi; Ramzy, Danny
title: Commentary: Ready or not, here it comes: Surgery after transcatheter aortic valve replacement
date: 2020-12-26
journal: JTCVS Tech
DOI: 10.1016/j.xjtc.2020.12.034
sha: 510090754d5c5604e144e7ad88bd37965076b3f3
doc_id: 996827
cord_uid: ib8xm4ba

nan

level, increasing left ventricular ejection fraction, nonelective cases, and nonfemoral access. 3 Low volume (<50 TAVRs annually) and high volume centers perform similarly in the frequency of surgical bailout and surgical bailout mortality. 4 In addition to a surgeon's readiness to intervene surgically, the ability to function well as a team is tantamount-as it is with high-level sports. Important anesthesia considerations must not be overlooked. These include readiness to safely and rapidly intubate and convert to general anesthesia, to provide massive transfusion if suddenly required, and to provide a safe time to pause the operation so anesthesia can catch up. Applying the team dynamics concepts from advanced cardiovascular life support, or advanced trauma life support may also be valuable.

While expanding on the author's mention of surgical bailout resulting from aortic dissection during TAVR, it is worth noting that both type A and type B aortic dissection are encountered. In patients who are poor surgical candidates, treatment considerations may include expectant management or endovascular devices, including investigational ascending aortic endovascular aortic repair.

The authors correctly comment on the paucity of longterm data on TAVR to predict valve durability, although some of the TAVR valves are beginning to show their age. In a recent analysis of TAVRs from 2012 to 2017, only 0.2% underwent surgical explant at a median of 212 days post-TAVR. And of this 0.2%, 30-day mortality associated Surgical bailout during TAVR occurs infrequently; however, mortality is high. A TAVR-first strategy may not be ideal, and this must be discussed by heart teams and with patients when considering TAVR.

with surgical explant was 13%-nearly double the mortality after reoperative surgical aortic valve replacement. 5 In an analysis of surgical explants after TAVR from the Society of Thoracic Surgeons database, operative mortality was 17% and was worse than expected for redo aortic valve replacement when the initial valve was surgically replaced. 6 Whereas it may be reassuring that the rates of surgical bailout and surgical explant for TAVR appear low to-date, mortality rates are alarmingly high. In addition to team readiness to perform these more challenging surgical procedures, it is equally important for cardiothoracic surgeons to first identify strategies to reduce mortality rates. Finally, we may have come to a time that a TAVR-first strategy may not be ideal for all patients, and we must include this important consideration in heart team discussions and patient counseling when considering TAVR in the first place.

STS-ACC TVT registry of transcatheter aortic valve replacement

Surgery after transcatheter aortic valve interventions

Incidence and outcomes of surgical bailout during TAVR: insights from the STS/ACC TVT registry

Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI)

Incidence, characteristics, predictors, and outcomes of surgical explantation after transcatheter aortic valve replacement

Reoperation after transcatheter aortic valve replacement: an analysis of the Society of Thoracic Surgeons database