A decade of cardiac surgery after transcatheter aortic valve replacement: Short-term clinical outcomes at a high-volume center

Background: The growing adoption of transcatheter aortic valve replacement (TAVR) in younger and lower-risk patients has increased the number of patients with other cardiac diseases requiring surgical intervention. Such surgeries pose unique technical challenges due to the presence of the TAVR, often requiring explantation. Despite increasing clinical relevance, outcomes of these operations remain poorly characterized. We sought to assess the incidence, indications, and short-term results of cardiac surgery following TAVR at a high-volume institution. Methods: This was a retrospective single-center analysis of patients undergoing any cardiac surgery post-TAVR between 2015 and 2024. Primary endpoints were perioperative all-cause mortality and stroke; secondary endpoints included cardiopulmonary bypass and cross-clamp times, as well as in-hospital and 30-day outcomes. Results: Among 10,898 surgeries, 61 (0.5%) involved patients with prior TAVR (median age, 72 years; 59% male), including 85% with hypertension, 28% with diabetes, 43% with chronic lung disease, and 15% with cerebrovascular disease. The median time between TAVR and surgery was 20 months, and 57% of the surgeries were urgent or emergent/salvage procedures. Major indications included TAVR dysfunction (28%), infective endocarditis (26%), and aortic pathology (13%). Common procedures were TAVR explant and surgical aortic valve replacement (n = 49), mitral surgery (n = 19), aortic root/arch surgery (n = 12), and multivessel coronary artery bypass grafting (n = 5). The median aortic cross-clamp and cardiopulmonary bypass times were 121 minutes and 160 minutes, respectively. The mortality rate was 13%. Other outcomes included stroke (3%), prolonged ventilation (31%), tracheostomy (7%), de novo dialysis (8%), need for postoperative blood products (61%), cardiac reintervention (10%), discharge to rehabilitation facility (34%), and readmission (13%). Conclusions: Cardiac surgery post-TAVR is uncommon and associated with significant morbidity and mortality. Prosthesis dysfunction and endocarditis are the leading indications, and TAVR explant remains a common although highly morbid intervention.