Successful Aortic Valve Replacement After Transcatheter Aortic Valve Implantation (TAVI) Following Initial Surgical Aortic Valve Replacement (SAVR): A Case Report

Introduction

Rheumatic aortic stenosis in young patients presents a unique and challenging clinical scenario. For high-risk patients, transcatheter aortic valve replacement (TAVR) offers a less invasive alternative to the standard surgical aortic valve replacement (SAVR) for treating severe symptomatic aortic stenosis. However, the long-term durability of TAVR in younger patients and the potential need for subsequent interventions remain significant concerns that are still being actively studied [1,2].

Redo SAVR following TAVR, particularly in patients who previously underwent SAVR, presents additional complexity. As the use of TAVR continues to expand, reports of redo SAVR after failed TAVR are increasing. This procedure carries inherently greater risk and potentially worse outcomes than primary SAVR [3]. This case highlights the clinical decision-making process involved in managing recurrent aortic stenosis in a young patient with a complex history of multiple valve interventions.

Case Report

THERAPEUTIC INTERVENTION AND TREATMENT PLAN:

Redo SAVR was recommended based on the patient’s recurrent severe aortic stenosis and the findings from imaging studies. Given the high surgical risk and prior sternotomy, peripheral femoral arterial and venous cannulation was prepared but ultimately not required, as careful sternal re-entry was achieved without major complications. Standard central aortic and bicaval cannulation was used for cardiopulmonary bypass (CPB) initiation. Extensive adhesiolysis was performed using a combination of sharp and blunt dissection to safely mobilize the right ventricle and great vessels. Myocardial protection was achieved using a single-dose of Del Nido cardioplegia administered antegrade and retrograde. The degenerated TAVR valve was surgically removed, and a 21-mm St. Jude Medical Regent mechanical valve was implanted (Figure 2). Postoperative transthoracic echocardiography demonstrated a mean transvalvular gradient of 10 mmHg, with preserved left ventricular ejection fraction (LVEF) of 45–50%. Careful hemodynamic monitoring and support in the ICU – including dobutamine and noradrenaline – were initiated postoperatively and gradually tapered to stabilize the patient’s condition. A postoperative drop in hemoglobin was managed with transfusion of 2 units of packed red blood cells. The use of the Edwards Sapien valve during the prior TAVR strategically minimized trauma to the aortic root. This proved beneficial during the redo surgery, allowing smoother and safer explantation of both prostheses. By reducing manipulation of the aortic root, the need for a more complex Bentall procedure was potentially avoided.

FOLLOW-UP AND OUTCOMES:

The patient’s postoperative course was remarkably smooth. She was extubated within 24 hours and maintained stable hemodynamics. The surgical wound remained clean and dry, and she was afebrile throughout her hospital stay.

Although TAVR had initially improved her ejection fraction, the presence of patient–prosthesis mismatch (PPM) likely contributed to the recurrence of symptoms. The patient was discharged with instructions for INR monitoring, wound care, and regular follow-up. Discharge medications included bisoprolol, ciprofloxacin, and warfarin, along with thorough education regarding their use and potential adverse effects.

Prior to redo surgery, she had a significantly reduced LVEF of 25%. Postoperative echocardiography confirmed recovery of normal LV function and a well-functioning mechanical valve.

Discussion

This is a unique and challenging clinical case of a young patient who underwent redo SAVR after TAVR, following an initial SAVR. Several interventions were required to manage the complexities associated with her history of rheumatic heart disease and progressive valve degeneration [4,5]. Although hemodynamic data following TAVR and redo SAVR were available and documented, immediate postoperative gradients from the initial SAVR in 2014 could not be retrieved due to the loss of archived records. The decision to proceed with redo SAVR was driven by the patient’s persistent symptoms and imaging evidence of severe aortic stenosis following TAVR.

The long-term durability of TAVR, particularly in younger patients, remains uncertain. While TAVR offers a less invasive option for high-risk individuals, its use in younger populations raises concerns about durability and the potential need for reintervention. TAVR followed by redo SAVR is associated with increased surgical complexity and risks, including injury to surrounding structures and increased bleeding. However, it can be performed successfully in carefully selected patients using meticulous surgical technique [7,8].

Common complications following TAVR include patient-prosthesis mismatch (PPM), particularly in valve-in-valve procedures, occurring in approximately 10–20% of cases [9]. Paravalvular leak occurs in 10–15% of patients [10]. Conduction disturbances – such as new left bundle branch block or atrioventricular block – are observed in 10–20% of cases, with 5–12% requiring permanent pacemaker implantation [11]. Structural valve complications such as thrombosis have an estimated incidence of around 15% in younger patients [12]. As TAVR becomes more common in younger age groups, the balance between procedural benefit and long-term risk must be carefully considered. A summary of the key benefits and limitations of SAVR and TAVR is presented in (Table 1) to aid clinical decision-making, particularly in complex redo cases.

The management of complex aortic valve interventions requires a multidisciplinary approach involving cardiologists, cardiac surgeons, and imaging specialists, as demonstrated in this case. Optimizing outcomes for patients undergoing multiple valve replacements depends on long-term follow-up and rigorous patient selection.

Conclusions

This case demonstrates that redo SAVR following prior TAVR can be both feasible and successful in a young patient with a history of multiple valve interventions. While TAVR offers a less invasive option for high-risk patients, it should be recognized that such patients – particularly younger individuals – may ultimately require subsequent surgical intervention.

The favorable outcome in this case was achieved through a tailored approach, meticulous surgical technique, and comprehensive postoperative care. Further research is warranted to better define the long-term outcomes of TAVR in younger populations and to refine criteria for patient selection in cases requiring redo SAVR after TAVR.