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Bioprosthetic Valve Fracture: A Practical Guide To Facilitate VIV TAVR
Keith Allen, Adnan Chhatriwalla, John Saxon, Chetan Huded, Hart Anthony.
St. Luke's Mid America Heart Institute, Kansas City, MO, USA.

OBJECTIVE: Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) is increasingly utilized to treat failed surgical valves; however, this technique has two Achilles Heals: 1) High residual gradients, particularly, in small surgical tissue valves resulting in patient-prosthesis mismatch and 2) transcatheter heart valves (THVs) are often constrained and not optimally expanded resulting in poor leaflet function. Bioprosthetic valve fracture (BVF) solves both of these issues by expanding the surgical valve 3-5 mm following fracturing thus reducing high residual gradient and allowing optimal THV leaflet function.
METHODS: This video tutorial provides a practical guide to performing BVF along with ‘tips and tricks' to avoid complications. BVF is applicable for both self-expanding and balloon expandable valves and is easily performed using rapid ventricular pacing and a high-pressure inflation of a non-compliant balloon following insertion of the THV.
RESULTS: BVF results in reduced residual transvalvular gradients and allows for optimal expansion of the THV which may impact both THV durability as well as improve patient outcomes following VIV TAVR. While complications can occur with BVF, they are uncommon and in one large multi center trial there were no annular ruptures, no coronary occlusions and no new pacemakers. In addition, follow-up on patients undergoing BVF demonstrated sustained gradient reduction at 1-year and a lower mortality compared to historical controls who did not have BVF.
CONCLUSIONS: BVF can be performed safely and facilitates VIV TAVR by reducing high residual transvalvular gradients and also allows optimal expansion of the THV with improved leaflet function.


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