TAVR Explantation: A Necessary Skill Set in the Contemporary Cardiac Surgery's Armamentarium

With the recent approval for transcatheter aortic valve replacement (TAVR) across all risk profiles, reintervention is likely to become common practice. As surgeons treat younger, fitter patients with longer life expectancies, complications such as thrombosis, endocarditis, non-structural valve deterioration and, of course, structural valve deterioration will warrant reintervention, which may require a high-risk surgical procedure in some cases. This video presents a case of a TAVR explantation due to nonstructural valve deterioration and severe aortic regurgitation due to perivalvular leak in a sixty-five-year-old man. The authors aim to emphasize both the technical aspects of the surgery and the importance of patient individualization for each procedure.The PatientThe patient is a sixty-five-year-old male without allergies, independent in daily activities, and with a medical history of HTA, COPD (former smoker of three packs per day), morbid obesity (BMI over 40), and ischemic heart disease with a chronic total occlusion (CTO) of the right coronary artery (RCA), which was untreated in his native country. He visited the authors’ center for two to three months of minimal effort dyspnea (NYHA III), angina, orthopnea, and lower limb oedema. Diagnostic studies revealed severe aortic regurgitation with severe LV dysfunction (LVEF less than 30 percent). The heart team discussion ended with the decision to perform TAVR. Immediately after the implantation, the patient developed AVB, LBHB, and ST elevation in anterior leads. Angiography revealed an acute thrombotic occlusion of the mid-LAD and an angioplasty with a stent was performed successfully. Follow up echocardiography showed a severe aortic regurgitation with a severe posterior perivalvular leak and LVEF of 35-40 percent. As the patient developed severe symptoms, he was scheduled for TAVR explantation and SAVR, as percutaneous closure of leak and valve-in-valve was technically difficult.The SurgeryThe procedure was performed under general anesthesia and conventional monitoring, as well as transesophageal echocardiography (TEE). A median sternotomy was performed, and cardiopulmonary bypass was started with atriocaval and aortic cannulation. A hemi-or mini sternotomy, or even other minimal invasive approaches, may be used if no further procedures are planned. Nevertheless, the possibility of aortic root damage and/or replacement, coronary arteries manipulation, and concomitant mitral valve surgery—if the ante