# Managing Transcatheter Aortic Valve Failure

## TL;DR

This review discusses the challenges and management strategies for patients who outlive their transcatheter aortic valves and face valve failure.

## Contribution

The paper provides a comprehensive algorithm and strategies for diagnosing and managing transcatheter aortic valve failure using both transcatheter and surgical approaches.

## Key findings

- Redo TAVR is preferred for most patients due to age and surgical risks, but it poses anatomical challenges.
- Surgical explantation remains vital for specific cases like endocarditis or anatomical incompatibility.
- A detailed algorithm is proposed to guide diagnosis and treatment of TAV failure.

## Abstract

As transcatheter aortic valve replacement (TAVR) expands rapidly into younger low-risk cohorts with long life expectancy, increasing numbers of patients will outlive their valves and present with bioprosthetic valve failure requiring treatment. Age, comorbidities, and the complexity of surgical explantation will make redo TAVR the preferred treatment option in the vast majority of patients. However, redo TAVR poses specific anatomical challenges, including an elevated risk of coronary artery obstruction, the preservation of coronary access, and optimization of hemodynamic outcomes and long-term durability, though few data exist to guide clinicians in the optimal procedural approach. Meanwhile, surgical explantation and valve replacement will remain a vital option in specific groups, including those with endocarditis and with anatomical features that prohibit redo TAVR.

This review article provides a detailed exposition of the challenges of both transcatheter and surgical treatment of transcatheter aortic valve failure, recommended strategies for diagnosis, preprocedural planning and procedural execution to deliver safe and effective outcomes, and a summary of the current evidence base in this growing field.

Algorithm for the diagnosis and management of TAV failure. Abbreviations: AR, aortic regurgitation; BAV, balloon aortic valvuloplasty; BEV, balloon-expanded valve; BVF, bioprosthetic valve failure; CMR, cardovascular magnetic resonance; CRP, coronary risk plane; CT, computed tomography; EOA, effective orifice area; HALT, hypoattenuated leaflet thickening; N, no; NSP, neoskirt plane; NSVD, nonstructural valve dysfunction; OAC, oral anticoagulation; OMT, optimal medical therapy; PET, positron emission tomography; PPM, prosthesis–patient mismatch; PVR, paravalvular regurgitation; SAVR, surgical aortic valve replacement; SEV, self-expanding valve; SURPLUS, Surgical Resection of Prosthetic valve Leaflets Under Direct ViSion; SVD, structural valve deterioration; TAV, transcatheter aortic valve; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiogram; TTE, transthoracic echocardiogram; Y, yes.

•With the expansion of transcatheter aortic valve (TAV) replacement (TAVR) into younger patients, TAV failure is an increasingly common clinical challenge.•The diagnosis of TAV failure may be challenging; this review summarizes the multimodality approach required.•Redo TAVR poses specific challenges to the operator, particularly in relation to coronary access and obstruction, and optimization of hemodynamics and subsequent durability. A step-by-step approach to preprocedural planning and effective procedural execution is described.•Surgical TAV explant retains a key role in patients with TAV endocarditis and anatomical contraindications to redo TAVR; this review details the precise surgical techniques required for optimal outcomes.•A comprehensive algorithm is presented for the overall approach to the diagnosis and management of TAV failure, both transcatheter and surgical, and for all failure mechanisms.

With the expansion of transcatheter aortic valve (TAV) replacement (TAVR) into younger patients, TAV failure is an increasingly common clinical challenge.

The diagnosis of TAV failure may be challenging; this review summarizes the multimodality approach required.

Redo TAVR poses specific challenges to the operator, particularly in relation to coronary access and obstruction, and optimization of hemodynamics and subsequent durability. A step-by-step approach to preprocedural planning and effective procedural execution is described.

Surgical TAV explant retains a key role in patients with TAV endocarditis and anatomical contraindications to redo TAVR; this review details the precise surgical techniques required for optimal outcomes.

A comprehensive algorithm is presented for the overall approach to the diagnosis and management of TAV failure, both transcatheter and surgical, and for all failure mechanisms.