What Are the Implications of Choosing a TAVR-First Strategy in the Lifetime Management of Aortic Stenosis?: A Critical Review of TAVR-Explant- and Redo-TAVR

Some patients with aortic stenosis may require multiple valve interventions in their lifetime, and choosing transcatheter aortic valve replacement (TAVR) as the initial intervention may be appealing to many. If their transcatheter heart valve degenerates later in life, most will hope to undergo redo-TAVR. However, if redo-TAVR is not feasible, some may have to undergo surgical explantation of their transcatheter heart valve (TAVR-explant). With rising numbers of TAVR in younger patients, we address the practical implications of choosing a TAVR-first strategy. In this review we explore potential factors contributing to higher-than-expected mortality after TAVR-explant, synthesize available outcomes data for TAVR-explant for structurally degenerated valves, and describe strategies to standardize and optimize surgical techniques for TAVR-explant. We also discuss clinical outcomes of redo-TAVR within the context of limitations in currently published series and highlight the potential benefit of virtual planning to assess the feasibility of future redo-TAVR before implanting the first valve. Finally, we highlight areas for future investigation to inform management strategies in patients who may require multiple aortic valve interventions.