SAVR vs. TAVR Re-Operation Rates: What Should Patients Know?

When patients with a surgical aortic valve replacement (SAVR) find out they need a re-replacement due to degeneration of the prosthetic valve, it’s no wonder a transcatheter aortic valve replacement (TAVR) looks very attractive. SAVR is a highly invasive procedure that involves opening the chest, stopping the heart, and several weeks or months of recovery. Conversely, TAVR is minimally invasive; the heart isn’t stopped, and patients can often leave the same day or the day after the procedure. TAVR seems like the best choice. However, over ten years of research and statistics now show that despiteTAVR’s appealing qualities, SAVR may be the better option.

We received a question from Chad about SAVR versus TAVR re-operations. Chad asked, “When researching re-operative techniques, I was surprised to see a dramatic difference between TAVR valve-in-valve and traditional surgical aortic valve re-replacement, with the latter appearing much safer for the long term. I was hoping that someday, valve-in-valve would be a good option, but it’s looking like that may not be the case. Can an expert on your team explain why the hazard ratio was nearly three times with valve-in-valve?”

We met with Dr. Edward Soltesz, a leading cardiac surgeon at the Cleveland Clinic in Cleveland, Ohio, to answer Chad’s question. During his extraordinary career, Dr. Soltesz has performed over 3,000 cardiac surgeries, with more than 2,200 heart valve procedures.

SAVR vs. TAVR Re-Operation Insights

Here are the key insights shared by Dr. Soltesz:

• The current data on SAVR versus TAVR. “Chad asks a very good question,” said Dr. Soltesz. “The issue is surrounding some of the recent data that came out looking at valve-in-valve TAVR after a previous surgical aortic valve replacement, and exactly what Chad said is true. They found a slightly higher risk of immediate complications with surgery. There was no difference in short-term mortality, but after two years, there seemed to be an improvement in survival among the re-operative surgical patients. So that begs the question as to what is going on here.” Dr. Soltesz explained that there have been several developments with the valve-in-valve TAVR and SAVR over the years.

• How are SAVR operations different? “About ten years ago, we realized that the re-operation risk for surgical re-operation disappeared from risk calculators,” said Dr. Soltesz. “That is to say, we’ve learned over the past 20 or 30 years how to reoperate on patients very safely by utilizing CT scans and reconstructing images of the patients’ inside to understand the topography. So, we know what to avoid and where to go, which has afforded us much lower rates of re-operative mortality.”

• Why are valve-in-valve procedures less durable? “When we talk about why a valve-in-valve is not providing durability in terms of survival beyond two years, it may be because you’re putting a valve inside another valve. Whenever you do that, there is a slight risk of patient prosthesis mismatch, and slight gradients develop, which can’t necessarily be predicted. I think the problem starts with the first valve,” said Dr. Soltesz.

• Surgeons individualize care for each patient. “I think when patients have their first valve, they must understand that we will look very closely at their risk profile as they age,” said Dr. Soltesz. “When we understand their risk profile, we can provide them with a risk estimate for reoperation and whether they should have re-operative surgery or a valve-in-valve procedure. As you can see from the data, a valve-in-valve is not always the best option. So, I think individualized care is required for patients, and we shouldn’t just offer valve-in-valve after a failed surgical valve replacement.”

• How can you and the Cleveland Clinic team find the correct valve the first time and reduce the complication of prosthesis mismatch? “One of the things we’ve recognized is the valve choice at the first operation or procedure is critical,” said Dr. Soltesz. “We understand that it is important to talk with the patient, have shared decision-making with them, and know that we need to implant a valve that is ideally going to last the longest for them while also providing a strategy for re-operation or re-replacement through a percutaneous means in the future by appropriately sizing the valve. Many times, we offer various types of root replacements for patients. We know from our data that minimally invasive valve surgery at the first operation confers to a lesser chance of needing blood products, a shorter ICU stay, and a quicker return to work at a subsequent procedure in the future.”

• Surgical expertise is the key. “We’re learning a lot about the lifetime management of aortic valve disease through the research we’ve been doing. The key is to have all the necessary surgical expertise available so that if a patient does require a root replacement or a root enlargement procedure, we have the facility to do that. We also can offer the breadth of aortic valve replacements from a Ross operation to a mechanical valve, tissue valve, and a TAVR.”

Thanks Dr. Soltesz and the Cleveland Clinic!

On behalf of all the patients in our community, thank you, Dr. Edward Soltesz, for everything you and your team are doing at the Cleveland Clinic in Cleveland, Ohio!

Related links:

• Learn more about Dr. Edward Soltesz
• Take a look at Cleveland Clinic’s Microsite
• Find out about Complex and High-Risk Valve Heart Valve Surgery

Keep on tickin,
Adam

P.S. For the deaf and hard-of-hearing members of our patient community, we have provided a written transcript of our interview with Dr. Soltesz below.