Bioprosthetic Valve Fracture to Facilitate ViV TAVR in Small Surgical Bioprostheses
Keith Allen1, Adnan Chhatriwalla1, John Saxon1, David J. Cohen1, Vinod Thourani2, Josh Rovin3, Anthony Bavry4, Tom C. Nguyen5, Richard Lee6, Brian Whisenant7, Mark J. Russo8.
1St. Luke's Mid America Heart Institute, Kansas City, MO, USA, 2Emory University School of Medicine, Atlanta, GA, USA, 3Morton Plant Hospital, Tampa Bay, FL, USA, 4University of Florida, Gainesville, FL, USA, 5University of Texas Medical School at Houston, Houston, TX, USA, 6Saint Louis University, St. Louis, MO, USA, 7Intermountain Heart Institute, Murry, UT, USA, 8Newark Beth Israel Medical Center, Newark, NJ, USA.
OBJECTIVE: Valve-in-Valve transcatheter aortic valve replacement (VIV-TAVR) in small surgical bioprostheses frequently results in high residual gradients, patient prosthetic mismatch (PPM) and reduced one-year survival. We evaluated the early hemodynamic results of bioprosthetic valve fracture (BVF) using a non-compliant balloon and a high-pressure inflation to fracture the surgical valve frame and facilitate VIV TAVR.
METHODS: From March 2016 through June 2017 BVF was performed in 34 consecutive patients undergoing VIV-TAVR at 11 US centers. Hemodynamic parameters and valve effective orifice area (EOA) at baseline, immediately after VIV TAVR and after BVF were analyzed.
RESULTS: Procedural success was 100% using both balloon-expandable (n=15) or self-expanding (n=19) transcatheter valves (Figure 1). Access was transfemoral (30), transcarotid (2), transcavel (1) and subclavian (1). Etiology of prosthetic valve dysfunction was aortic stenosis (24), aortic insufficiency (6) and mixed (4). Median baseline prosthetic valve gradient in patients with aortic stenosis was 44 mmHg (IQR 38,60). BVF was performed after VIV TAVR in 30 patients while BVF was performed prior to VIV TAVR in 4 patients. BVF reduced the median transvalvular gradient following VIV-TAVR from 24 mmHg (IQR 17,36) to median 7 mmHg (IQR 4,12;p<0.001) with an increase in median valve EOA from 0.95 cm2 (IQR 0.8,1.2) to 1.8 cm2 (IQR 1.3,2.1;p<0.001). There were no aortic root disruptions or coronary occlusions, no new permanent pacemaker implants and 30-day survival was 100%. Complications included non-disabling stroke (1) on POD#2, new moderate mitral regurgitation managed medically (1) and transcatheter valve insufficiency requiring 2nd valve (1). Aortic insufficiency was either none (n=32) or trivial (n=2) at the conclusion of the case.
CONCLUSIONS: BVF to facilitate VIV-TAVR in small surgical valves results in reduced residual gradients, resolution of PPM and increased EOA. Continued evaluation of this technique is warranted to refine procedural techniques and determine long term clinical outcomes and BVF's effect on transcatheter VIV durability.
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