Mastering Redo Surgery After TAVR: Annular Rupture Repair After TAVR and TAVR Explant After CABG With MVR

In this series of videos, Dr. Vincent Gaudiani shares his experience in the new field of surgery after previous TAVR and provides his tips for safely performing redo surgery for a variety of indications including TAVR early and late failure, endocarditis, and when further valve surgery is required.

In this video, the patient underwent TAVR, but a pericardial collection was identified during the operation. The patient was initially stable, but after two days and further imaging a contained aortic annulus rupture was diagnosed and he was taken urgently to the operating room.  

The new TAVR was relatively straightforward to remove using the handlebar mustache technique, scissors, and a wire cutter.  The annulus was debrided, and the aortic rupture was found under the left main stem.  

A Dacron patch was placed over the defect and then the pledgeted 2.0 sutures were placed for the 25mm valve over the patch and the operation was completed. 

This video shows a patient who had CABG 20 years prior, and then TAVR two years prior to developing aortic regurgitation.

First, a redo sternotomy was performed, preserving the vein grafts. The angiogram of the vein to LAD showed that the patient was suffering from classical angina preoperatively. In the operation, this graft was found to be profoundly calcified.

Next, the TAVR valve was explanted with the handlebar mustache technique. A small area of aorta was damaged, but was repaired using the pledged sutures for the annulus that would be used to suture the AVR into place. 

A mitral valve replacement was then performed to treat the patient’s mitral valve regurgitation. This was performed through the roof of the left atrium rather than Sondegaarde’s groove. Although the incision is not as wide as in Sondegaarde’s groove, the view of the valve is still satisfactory. One advantage of this approach is that sutures can be placed from the aortic side and through into the left atrium.

Next, the calcified vein to LAD was resected and the vein was cut down across the anastomosis with the LAD. A vein patch was sutured to the proximal vein, where it was not calcified, in order to revise the twenty-year-old graft. Finally, after the valves were placed with core knots and the atrium and aorta were closed with a single layer 3.0 proline, an LV pacing lead was placed lateral to the PDA as the patient had a pacing system already in place. His EF was only 30 percent, so the pacemaker was upgraded to a CRT device postoperatively to optimize biventricular contraction.

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