Bioprosthetic Valve Fracture During Valve-in-valve TAVR: Bench to Bedside

Abstract

Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) has been established as a safe and effective means of treating failed surgical bioprosthetic valves (BPVs) in patients at high risk for complications related to reoperation. Patients who undergo VIV TAVR are at risk of patient-prosthesis mismatch, as the transcatheter heart valve (THV) is implanted within the ring of the existing BPV, limiting full expansion and reducing the maximum achievable effective orifice area of the THV. Importantly, patient-prosthesis mismatch and high residual transvalvular gradients are associated with reduced survival following VIV TAVR. Bioprosthetic valve fracture (BVF) is as a novel technique to address this problem. During BPV, a non-compliant valvuloplasty balloon is positioned within the BPV frame, and a highpressure balloon inflation is performed to fracture the surgical sewing ring of the BPV. This allows for further expansion of the BPV as well as the implanted THV, thus increasing the maximum effective orifice area that can be achieved after VIV TAVR. This review focuses on the current evidence base for BVF to facilitate VIV TAVR, including initial bench testing, procedural technique, clinical experience and future directions.

Keywords: Transcatheter aortic valve replacement; aortic stenosis; bioprosthetic valve fracture; patient–prosthesis mismatch; valve-in-valve TAVR.

Conflict of interest statement

Disclosure: Dr. Chhatriwalla receives research and clinical trial support from, acts as a proctor of, and is on the speakers bureau of Medtronic, Edwards Lifesciences and St. Jude Medical. Dr. Cohen receives research and clinical trial support from Medtronic, St. Jude Medical, and Edwards Lifesciences. Dr. Allen receives research support from Abbott Medical and Edwards Lifesciences, and is on the speakers bureau of Edwards Lifesciences and Medtronic. Dr. Saxon has no disclosures.

Figures

Figure 1:. Technique of High-pressure Balloon Inflation to Perform Bioprosthetic Valve Fracture

Figure 2:. Fractured 21 mm Mitroflow Bioprosthetic Valve

Figure 3:. A: Baseline Appearance of 23 mm Magna BPV after Deployment of 26 mm Medtronic Evolut R THV. B: Initial Balloon Inflation During BVF. C: Appearance of BPV and Balloon after BPV Ring Fracture. Note the Visible Release of the Balloon Waist and Expansion of BPV Compared to (B). D: Final Appearance after VIV TAVR and BVF

Figure 4:. A: Baseline Haemodynamics Prior to VIV TAVR. The Mean Gradient was Measured at 39 mmHg and the Mean EOA was Calculated at 0.7 cm2. B: Post-VIV TAVR. The Mean Gradient was Measured at 25 mmHg and the EOA was Calculated at 1.2 cm2. C: Post-BVF. The Final Mean Gradient was Measured at 3 mmHg and the EOA was Calculated at 1.7 cm2