Redo-Transcatheter Aortic Valve Implantation Versus Surgical Explantation in Patients With Previous Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis.

BACKGROUND: 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. This 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. METHODS: PubMed/Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched from inception to September 10, 2025 for comparative studies. 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. As the primary analysis, reconstructed individual patient-level data were analyzed using Firth penalized logistic regression adjusting for study, and complementary random-effects meta-analyses were also used. RESULTS: Eight observational studies including 6166 patients (3743 redo-TAVI; 2425 TAVI-explantation) were analyzed. Compared with TAVI-explantation, redo-TAVI was associated with lower in-hospital mortality (odds ratio [OR], 0.20 [95% CI, 0.11-0.35]; P<0.0001), 30-day mortality (OR, 0.28 [95% CI, 0.23-0.34]; P<0.0001), and 1-year mortality (OR, 0.70 [95% CI, 0.62-0.80]; P<0.0001). No significant differences were observed in cerebrovascular events or permanent pacemaker implantation rates. Redo-TAVI was associated with lower major bleeding (OR, 0.35 [95% CI, 0.24-0.50]; P<0.0001), fewer 30-day readmissions (OR, 0.53 [95% CI, 0.30-0.92]; P=0.023), and shorter hospitalization (Mean Difference -6.29 days [95% CI, -8.66 to -3.93), but a higher risk of greater-than-mild paravalvular leak (OR, 80.12 [95% CI, 11.30-10 153]; P<0.0001). CONCLUSIONS: Redo-TAVI was associated with lower early and 1-year mortality, reduced bleeding, and shorter hospitalization compared with TAVI-explantation, with similar cerebrovascular event and permanent pacemaker implantation rates but higher paravalvular leak risk. These findings support redo-TAVI as the preferred reintervention strategy in anatomically suitable patients, whereas randomized trials and longer-term follow-up are needed to refine lifetime management strategies after transcatheter heart valve failure.