# APBA Kısa Özet

Redo-Transcatheter Aortic Valve Implantation (redo-TAVI) versus surgical explantation in patients with prior transcatheter aortic valve implantation: a systematic review and meta-analysis. Redo-TAVI is associated with lower in-hospital and 1-year mortality, reduced bleeding, and shorter hospitalization compared to surgical explantation, but carries a higher risk of greater-than-mild paravalvular leak. Cerebrovascular events and permanent pacemaker implantation rates are similar between the two strategies.

# Çalışma neyi araştırdı?

This systematic review and meta-analysis aimed to compare the outcomes of redo-TAVI (TAVI-in-TAVI) versus surgical transcatheter heart valve explantation with surgical aortic valve replacement (TAVI-explantation) after transcatheter heart valve failure. As transcatheter aortic valve implantation (TAVI) expands to younger and lower-risk populations, failed transcatheter heart valves are increasingly encountered, yet the optimal reintervention strategy remains uncertain. The primary outcome was all-cause mortality (in-hospital, 30-day, and 1-year). Secondary outcomes included cerebrovascular events, major adverse cardiac events, permanent pacemaker implantation, greater-than-mild paravalvular leak, major bleeding, length of stay, and 30-day readmission. Databases including PubMed/Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched from inception to September 10, 2025 for comparative studies. The analysis included 17 comparative studies encompassing 6,166 patients. As the primary analysis, reconstructed individual patient-level data were analyzed using Firth penalized logistic regression to address small-sample bias and separation issues. Fixed-effect or random-effects models were used depending on heterogeneity. Outcome measures included mortality at multiple time points, bleeding complications, valve leakage, pacemaker dependence, and hospital length of stay. The methodological quality was assessed using GRADE, and risk of bias was judged as "some concerns."

# Yöntem

The analysis included 17 comparative studies encompassing 6,166 patients. As the primary analysis, reconstructed individual patient-level data were analyzed using Firth penalized logistic regression to address small-sample bias and separation issues. Fixed-effect or random-effects models were used depending on heterogeneity. Outcome measures included mortality at multiple time points, bleeding complications, valve leakage, pacemaker dependence, and hospital length of stay. The methodological quality was assessed using GRADE, and risk of bias was judged as "some concerns."

# Temel bulgular

  • In-hospital mortality: Redo-TAVI was associated with lower in-hospital mortality (OR, 0.20 [95% CI, 0.11–0.35]; P = 0.023).
  • 1-year mortality: Redo-TAVI was associated with lower 1-year mortality compared to surgical explantation (pooled OR 0.65 [95% CI, 0.48–0.88]; P = 0.006).
  • Greater-than-mild paravalvular leak: Redo-TAVI was associated with a higher risk of greater-than-mild paravalvular leak (OR, 80.12 [95% CI, 11.30–101.53]; P < 0.0001).
  • Major bleeding: Redo-TAVI was associated with reduced major bleeding (OR, 0.55 [95% CI, 0.38–0.80]; P = 0.002).
  • Hospitalization: Redo-TAVI was associated with shorter hospitalization (Mean Difference -6.29 days [95% CI, -8.66 to -3.93]).
  • Cerebrovascular events: Similar rates between redo-TAVI and surgical explantation.
  • Permanent pacemaker implantation: Similar rates between the two strategies.

# Bulgular ne anlama geliyor?

Redo-TAVI appears to be a safer option in terms of mortality, bleeding, and hospital resource utilization compared to surgical explantation. However, the significantly higher risk of greater-than-mild paravalvular leak with redo-TAVI necessitates careful patient selection and informed consent. The similar rates of cerebrovascular events and permanent pacemaker implantation suggest that both strategies have comparable safety profiles regarding neurological and conduction system outcomes. Clinicians should weigh the mortality and bleeding benefits of redo-TAVI against the risk of significant valve leakage when recommending a reintervention strategy. Heart team discussion should consider valve type, size, and anatomical factors that may influence leak risk. For patients in whom paravalvular leak is a major concern, surgical explantation may be the more appropriate strategy despite higher periprocedural risks.

# Klinik önem

The findings suggest that redo-TAVI may be preferred over surgical explantation for patients where the priority is reducing mortality and bleeding risk and minimizing hospital stay. However, the substantially higher odds of greater-than-mild paravalvular leak (OR ~80) must be communicated to patients. Heart team discussion should consider valve type, size, and anatomical factors that may influence leak risk. For patients in whom paravalvular leak is a major concern, surgical explantation may be the more appropriate strategy despite higher periprocedural risks.

# Sınırlılıklar

This meta-analysis has several limitations. The included studies were observational, and residual confounding cannot be excluded. Firth penalized logistic regression was used for individual patient data analysis, which, while methodologically robust, relies on reconstructed data. Longer-term follow-up beyond 1 year was not available. Device-specific effects were not analyzed. There is potential publication bias in the observational literature. The sample, while large, comprises patients from heterogeneous clinical practice settings. The applicability of findings to low-volume centers or specific valve types requires further investigation. Additionally, the lack of randomized controlled trial data limits the strength of causal inference regarding reintervention strategy selection.