TAVI in SAVR Explantation: A Two-Step Technique for Successful Removal

Patient Data 

In this video, the authors discuss the case of a 79-year-old female who underwent surgical aortic valve replacement (SAVR) in 2011 with the implantation of a 19 mm bioprosthesis. In 2018, a transcatheter aortic valve implantation (TAVI) in SAVR was performed due to bioprosthesis degeneration, and subsequently, in 2024, she underwent balloon dilatation for early degeneration of TAVI. 

The patient was hospitalized in the surgeons’ department for worsening dyspnea (New York Heart Association (NYHA) class-III).  
 
The transesophageal echocardiography showed a dilated left ventricle (LV) with preserved ejection fraction (EF) and severe aortic stenosis (mean gradient 73 mmHg, aortic valve area (AVA) 0.45 cm2).  
 
A TAVI in TAVI procedure was deemed unfeasible due to patient-prosthesis mismatch and difficulties in protecting the coronary ostia. The patient was then scheduled for surgery with TAVI removal and replacement of the aortic bioprosthesis. The aortic cannulation and cross-clamp sites were planned based on computed tomography (CT) scan imaging. 
 
Snare Technique 

After administrating retrograde del Nido cardioplegic solution, a distal aortotomy with an almost complete transection of the aorta was performed.  
 
In the first step, the TAVI frame was carefully separated from the aortic wall. A 1-0 Ethibond row was passed inside-out through the top cells of the TAVI frame and then snared on a tourniquet to easily collapse the prosthesis, separating it from the aortic wall. 
 
Double Kocher Roll Technique 

In the second step, a double Kocher roll technique was employed to explant the TAVI from the aortic bioprosthesis. Two Kochers were placed at 180° on the TAVI cuff and rolled simultaneously inward to collapse the valve, allowing for easier removal. 

Removing the Aortic Bioprosthesis 

The degenerated bioprosthesis was then removed in the conventional manner, taking care not to damage the aortic annulus. A new 21 mm bioprosthesis was sized and implanted with three 2-0 polypropylene running sutures. 

Repairing the Aortic Wall 

A small iatrogenic laceration in the aortic endothelium caused during the TAVI explanation was repaired with a 5-0 polypropylene running suture. The aortotomy was finally closed between two 4-0 polypropylene running sutures. 
 
Postoperative Course 

The postoperative course was uneventful, and the patient was discharged on postoperative day seven. 

References

1. Brescia AA, Kachroo P, Kaneko T. Transcatheter aortic valve replacement explant various techniques. Ann Cardiothorac Surg. 2025 Mar 31;14(2):157-164. doi: 10.21037/acs-2024-etavr-12. Epub 2025 Mar 27. PMID: 40270851; PMCID: PMC12013762.]

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