Long-Term Reintervention, Clinical Valve Failure, and Outcomes After Transcatheter Aortic Valve Replacement: A National Real-World Study

Background As transcatheter aortic valve replacement (TAVR) expands to younger patients with longer life expectancy, understanding long-term reintervention and clinically significant valve failure has become increasingly important. Objectives To evaluate temporal trends in TAVR outcomes, characterize the incidence and timing of aortic valve reintervention, compare outcomes after redo-TAVR (TAVR-in-TAVR) versus surgical explantation, and assess freedom from clinically significant valve failure requiring repeat intervention after TAVR versus surgical bioprosthetic aortic valve replacement (SAVR). Methods We performed a retrospective cohort study using the Epic Cosmos. Adults undergoing index TAVR between February 2010 and May 2026 were identified. Primary outcomes included aortic valve reintervention and 30-day major adverse cardiovascular events (MACE). Reintervention incidence was estimated using competing-risk methods with death as the competing event. Propensity-score matching compared redo-TAVR with surgical explantation and TAVR with SAVR. A prespecified 1-year landmark analysis evaluated clinically significant valve failure requiring repeat intervention. Results Among 300,927 patients undergoing TAVR, annual procedural volume increased more than tenfold between 2016 and 2025. Thirty-day MACE decreased from 31.8% before 2017 to 18.6% after 2022 (P<0.001), while mortality declined from 3.0% to 1.4% (P<0.001). During follow-up, 3,315 patients underwent redo-TAVR and 347 underwent surgical explantation. The cumulative incidence of reintervention was 1.1%, 1.2%, 1.5%, and 2.7% at 3, 5, 7, and 10 years, respectively, with significantly lower rates in contemporary procedural eras (Gray test, P<0.001). Compared with surgical explantation, redo-TAVR was associated with lower 30-day mortality, stroke, acute kidney injury, and major bleeding. However, among propensity-matched hospital survivors, surgical explantation was associated with superior long-term survival (hazard ratio: 0.64; 95% CI: 0.44 - 0.93; P=0.018). In the landmark analysis, clinically significant valve failure requiring repeat intervention occurred earlier after TAVR than after SAVR despite a lower overall cumulative incidence of repeat intervention following TAVR. Conclusions Contemporary TAVR is associated with progressively improving procedural outcomes and a low incidence of repeat aortic valve intervention. Redo-TAVR offers lower perioperative risk than surgical explantation, whereas surgical explantation is associated with superior long-term survival among selected patients. Earlier clinically significant valve failure requiring repeat intervention after TAVR underscores the importance of lifetime management strategies as TAVR expands to younger populations.