Mortality at 4 Years After TAVI Explant Linked to Hospital Volume: Medicare Data

COPENHAGEN, Denmark—Patients undergoing SAVR for failed TAVI have better four-year survival when they are treated at centers with more experience in explantation, according to new US Centers for Medicare & Medicaid Services (CMS) data.

The findings suggest that TAVI explant, which is the fastest growing cardiothoracic surgical procedure and has been linked to poor outcomes overall, should be limited to hospitals performing the most of these surgeries, researchers say.

“Given the fact that [TAVI] explant remains to be a relatively novel and evolving procedure, centralization to high-volume centers may be of benefit to patients,” said Allen Razavi, MD (Cedars-Sinai Medical Center, Los Angeles, CA), who presented the data in a moderated poster session at the 2025 European Association for Cardio-Thoracic Surgery meeting.

“TAVR explant is a tough operation,” he told TCTMD. “[As] the number of people that get more and more familiar with the operation increases, then ‘regionalization’ will likely probably not be [as necessary as] the techniques have dispersed.”

Commenting on the study, Shinichi Fukuhara, MD (University of Michigan, Ann Arbor), who has performed more than 140 TAVI explants to date and has presented data showing that this surgery is associated with better outcomes than redo TAVI, said the total procedural volume is likely still too small to effectively analyze a volume-outcome relationship.

Moreover, the cutoff of eight surgeries used in this study to denote “high” volume is likely far too low, he said. That number should be at least 50 per surgeon, not per institution, and there are “less than 10 surgeons in the entire country” who currently meet that threshold.

Also, Fukuhara added, TAVI explants are “naturally centralizing” within the United States based upon the where the surgeons with experience in the procedure are located. For example, three institutions are performing 98% of TAVI explants within Michigan, he said.

In urban areas in, say, New York and California, it’s likely that “cases are probably more scattered rather than centralized,” Fukuhara said. “That’s my suspicion.”

Lower Mortality With More Experience

The analysis focused on 660 adults age 65 years and older (mean age 69 years) from the CMS database who underwent TAVI explant between 2012 and 2022. Patients were stratified into tertiles by overall hospital procedural volume: high (≥ 8 explants; n = 189), medium (4-7 explants; n = 331), and low (≤ 3 explants; n = 140). Notably, those having surgery at high-volume centers were more likely to have prior valve intervention (36.5%) and be undergoing concomitant procedures (60.8%) compared with those having surgery at medium- and low-volume centers.

Total TAVI explant volume increased over time, though the proportion of procedures performed at high-volume hospitals stayed relatively stagnant at about 30%.

The primary endpoint of all-cause mortality at 4 years was significantly lower at high- compared with low-volume centers (adjusted HR 0.61; 0.40-0.91), though this advantage was not seen for medium-volume hospitals (adjusted HR 0.81; 95% CI 0.56-1.15).

However, there were no significant differences observed in the secondary endpoints of mortality, bleeding, stroke, atrial fibrillation, and need for pacemaker at 30 days nor in median hospital length of stay, which was 13 days for each cohort.

It was likely the nearly 2-week hospital stay that negated the ability to see any differences in mortality or other outcomes at 30 days, according to Razavi. “That divergence probably starts around 1 year,” he said, adding that he has plans to conduct more analyses looking to see if there are any differences at 3 or 6 months.

For now, Razavi said he’d mostly like to see careful consideration into which patients are offered these surgeries and where they’re done. “It comes down to the surgeon who’s going to be taking on the case and how comfortable they feel with this, [especially] if they have someone that they can rely on who’s done it before,” he said. “In the end, we just want to do what’s good for the patient. . . . If you’re not comfortable with it, that’s okay. There are other places that can help.”