A risk model allowing cardiologists and their patients to share decision-making about undergoing surgery after transcatheter aortic valve replacement (TAVR) had received high marks for its accuracy in identifying patients who fall into the low-risk category.

To validate the risk model, Robert B. Hawkins, MD, MSc, of the Department of Cardiac Surgery and assistant professor of surgery at the University of Michigan Health in Ann Arbor, and colleagues analyzed 5708 patients from the Society of Thoracic Surgeons Adult Cardiac Surgery database. Approximately 40% of patients were cases of isolated surgical aortic valve replacement (SAVR) after prior TAVR. In all, 59.7% underwent related procedures such as coronary artery bypass grafting and concomitant aortic root procedures.

Hawkins presented the results of the study at the Society of Thoracic Surgeons (STS) 2026 Annual Meeting.

The study revealed that from 2014 to 2025, the rate of operative mortality for isolated cases of surgery after TAVR in patients who might be candidates for redo-TAVR, which excluded endocarditis, root enlargement, and emergent cases, continued to drop. Specifically, the rate of operative mortality was 13.1% between the years of 2014 and 2016 and fell to 5.6% between 2017 and 2019, 4.3% between 2020 and 2022, and 3.5% between 2023 and 2025.

These findings, the researchers explained, offer critical real-world proof that aligns with prior reports and shows improvement in patient selection, timeliness of referrals, surgical performance, and perioperative care.

Success, but Also Caution

Compared with first-time TAVR, or even redo-TAVR after prior surgery, Hawkins pointed out that TAVR valve explant may pose complications. These complications are due to factors such as stent ingrowth into the aorta, risk for coronary obstruction that limits myocardial protection, and potential injury to the root, coronary ostia, or ascending aorta, he said. These factors can result in longer operative times that may increase perioperative risk, Hawkins added.

“While the study was not focused on identifying risks specific to the TAVR explant, it did show that over time, most complications such as renal failure, prolonged ventilation, stroke, or death, have decreased,” Hawkins said. “This decrease was driven by two factors: patients at lower risk are having TAVR and thus are undergoing TAVR explant, and surgeons and cardiac teams are showing improved disease management.”

He pointed out that the use of TAVR is rapidly increasing among younger, healthier patients seeking to avoid longer hospital stays and recovery periods. He noted that continual improvements in surgical techniques also played a role in operative mortality rates.

Outside Perspectives

Better risk stratification may help to reduce inappropriate nonoperative or suboptimal interventional management of failed TAVR valves as well as delays in surgical referral, said Shinichi Fukuhara, MD, of the Department of Cardiac Surgery at the University of Michigan Health. Fukuhara was not involved in the study.

“Early reports demonstrated operative mortality approaching 20%, which understandably generated significant hesitation toward surgical TAVR valve explantation,” Fukuhara said. “As a consequence, some patients with failed TAVR valves — particularly those without favorable redo-TAVR anatomy — may have undergone suboptimal alternative strategies,” he said.

“It is not uncommon for patients with confirmed degenerated TAVR valves to seek multiple opinions over several months in an effort to avoid surgery,” Fukuhara said. “However, by the time they are evaluated by a cardiac surgeon, many present with advanced heart failure and declining renal function.”

By identifying patients who can safely undergo surgery after TAVR, cardiac surgeons can intervene in a more timely and appropriate manner, which may ultimately improve long-term outcomes for this rapidly growing population of TAVR recipients, Fukuhara said.

Gorav Ailawadi, MD, MBA, chair in the Department of Cardiac Surgery at the University of Michigan Health, who also was not involved in the study, said the results provide reassurance that TAVR explant is getting better and improving.

“Yet we should remain cautious about considering a TAVR-first strategy in everyone as the mortality is still higher than an isolated SAVR,” Ailawadi said. “These findings support a strong relationship between surgeons and cardiologists for the care of aortic valve patients.”

Ailawadi added that with the rise in TAVR procedures, particularly in younger and low-risk patients, TAVR explantation has become more common and outcomes have improved.

“For the best outcome, having surgeons present at the TAVR still is the safest for patients,” he said. “Many patients need concomitant procedures — these should be considered in decisions about SAVR vs TAVR at the index decision.”

Looking Ahead

To provide accurate up-to-date estimates to help cardiac teams and patients share in the decision-making process, a user-friendly online interface is in the works, Hawkins said.

Hawkins would like to see future research examine a larger database over the lifetime of patients as well as better collaboration between the fields of cardiology and cardiac surgery.

“Our goal is to optimize the management of aortic valve disease, whether it be transcatheter, surgical, repair or replacement, mechanical, or bioprosthetic,” Hawkins said. “Linking transcatheter valve therapy with the STS databases will allow clinicians to track patients throughout the management of their disease.”

Hawkins reported having no financial disclosures. Fukuhara reported serving as a consultant for Medtronic, Inc.; Edwards Lifesciences; LeMaitre; LifeNet Health; Artivion; and Terumo Aortic.

Martta Kelly is a medical journalist living in the New York metropolitan area. Brian Ellis is a freelance writer and editor who lives in Southwest Virginia.