Techniques for Explantation of Transcatheter Aortic Bioprosthesis

Background

Transcatheter aortic valve replacement (TAVR) is now widely used for the management of aortic stenosis. As indications expand to include younger and lower-risk patients, surgical explantation of failed TAVR prostheses is being encountered more frequently. TAVR explantation is technically demanding due to the extensive endothelialization of the device and its integration with the aortic wall and surrounding structures, creating significant operative challenges (1, 2).

General Surgical Principles

1. Access and Visualization

Explantation is typically performed via median sternotomy, although less invasive approaches may be selected based on patient factors. Cardiopulmonary bypass with cardioplegic arrest is essential to provide a stable, bloodless field. The aortotomy should be tailored to valve type—a low aortotomy near the sinotubular junction for balloon-expandable valves and a higher aortotomy for self-expanding valves (3).

2. Assessment and Dissection

The extent of endothelialization and adhesion to the aortic wall must be carefully assessed. A dissection plane is developed circumferentially around the prosthesis. This step becomes increasingly challenging with longer implant duration due to progressive neo-endothelial ingrowth (1).

3. Device Manipulation

Reduction of radial force is critical for safe extraction. This is achieved by collapsing or recapturing the stent frame using clamps, snares, or tourniquets to allow controlled reduction of device diameter (3, 4).

4. Aortic Wall Protection

Meticulous endarterectomy is required to separate the prosthesis from the aortic wall while minimizing injury. Surgeons must be prepared for patch repair or full aortic replacement if significant wall damage occurs (1).

Specific Explant Techniques

1. Standard Dissection and Frame Collapse

After circumferential removal of neo-endothelial tissue, a Kocher clamp can be applied to deform and collapse the stent frame, facilitating extraction. Taller self-expanding valves often require a double Kocher clamp technique for improved control (1).

2. Snaring Techniques

Several snaring methods have been described. A heavy suture loop can be placed around the prosthetic frame and tightened incrementally to reduce diameter and allow mobilization (4). In the chest tube snaring method, a looped suture is passed through a rigid tube acting as a tourniquet. Progressive tightening collapses the valve and permits en-bloc removal with reduced aortic trauma (5). In difficult cases, a sponge stick may be used to rotate and corkscrew the collapsed prosthesis out of the aorta (3).

3. “Lasso” Collapse Technique

This approach employs sequential polyester snaring sutures tightened with tourniquets to gradually constrict the valve frame. The technique creates space for careful dissection from the aortic wall and may reduce bypass and cross-clamp times (4).

4. Auxiliary Methods

Additional techniques include the use of a circumferential suture combined with a heart valve sizer to collapse the nitinol frame in a controlled manner (6). Cold saline lavage has historically been used to assist collapse of self-expanding valves, although mechanical methods alone are often sufficient (3).

Technical Challenges

Extensive neo-endothelialization in long-standing implants necessitates careful endarterectomy. Aortic wall injury remains a major risk and may require patch repair or graft replacement. Valve type influences difficulty. Balloon-expandable valves are shorter and often easier to collapse, whereas self-expanding valves extend higher into the aorta and frequently require snaring or rotational techniques (3).

Clinical and Outcomes Context

Although still uncommon, TAVR explantation is increasing and is associated with higher morbidity and mortality compared with isolated surgical aortic valve replacement (AVR), reflecting both device-related complexity and patient risk profiles (2, 7). Concomitant procedures, such as aortic repair or coronary bypass, are frequently required, further complicating operative planning (2).

References

1. 1. Fukuhara S, Brescia AA, Shiomi S, Rosati CM, Yang B, Kim KM, Deeb GM. Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications. J Thorac Cardiovasc Surg. 2021 Aug;162(2):539-547.e1. doi: 10.1016/j.jtcvs.2019.11.139. Epub 2020 Jan 12. PMID: 32037245; PMCID: PMC7388726.
   2. Yokoyama Y, Kuno T, Zaid S, Kaneko T, Takagi H, Tang GHL, Fukuhara S. Surgical explantation of transcatheter aortic bioprosthesis: A systematic review and meta-analysis. JTCVS Open. 2021 Sep 20;8:207-227. doi: 10.1016/j.xjon.2021.09.023. PMID: 36004168; PMCID: PMC9390557.
   3. Valdis M, Hage F, Diamantouros P, Bagur R, Teefy P, Chu MWA. Snaring technique for explantation of transcatheter aortic valve bioprosthesis. Ann Cardiothorac Surg. 2020 Nov;9(6):534-536. doi: 10.21037/acs-2020-av-18. PMID: 33312919; PMCID: PMC7724059.
   4. Yun Seok Kim, Jae Suk Yoo, Easy surgical explantation technique for self-expanding transcatheter aortic valve: ‘lasso technique’, Interactive CardioVascular and Thoracic Surgery, Volume 34, Issue 4, April 2022, Pages 691–693, https://doi.org/10.1093/icvts/ivab304.
   5. Nasir Chatha H, Papus M, Rafael Baeza C. Recapturing Technique for TAVR Explant—A Safe Operative Method. June 2025. doi:10.25373/ctsnet.29274713.
   6. Parra-Salazar JJ, Vera-Domínguez E. Valve in TAVR: surgical explantation of transcatheter aortic valve. Cir Card Mex. 2024;9(3):91-95. doi:10.35366/116098.
   7. Tsiouris A, Protos AN, Shake JG, Coimbatore Jeyakumar AK. Surgical Technique And Clinical Implications Of Transcatheter Aortic Valve Bioprosthesis Explantation. Port J Card Thorac Vasc Surg. 2024 May 13;31(1):12-16. doi: 10.48729/pjctvs.377. PMID: 38743522.

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