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. 2024 Nov 22;51(2):e238304.
doi: 10.14503/THIJ-23-8304. eCollection 2024 Jul-Dec.

Effects of Bioprosthetic Valve Fracturing on Valve-in-Valve Transcatheter Aortic Valve Implantation Transvalvular Gradients

Osama Hallak  1 , Karley Fischer  2 , Shaina Ailawadi  2 , Damian Valencia  1   2 , Yan Yatsynovich  1   2 , Raja Nazir  1   2 , Brian Schwartz  1   2
Affiliations

Effects of Bioprosthetic Valve Fracturing on Valve-in-Valve Transcatheter Aortic Valve Implantation Transvalvular Gradients

Osama Hallak et al. Tex Heart Inst J. .

Abstract

Background: Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is quickly becoming a routine and effective means by which to treat degenerated bioprosthetic valves. A known complication of ViV-TAVI is patient-prosthesis mismatch, which substantially affects survival. Bioprosthetic valve fracture is a method by which to reduce the risk of patient-prosthesis mismatch and post-ViV-TAVI transvalvular gradients. This study sought to determine the safety and efficacy of post-ViV-TAVI bioprosthetic valve fracture.

Methods: Patients with a history of surgical aortic valve replacement undergoing ViV-TAVI bioprosthetic valve fracture (N = 25) at the corresponding institution from 2015 to 2022 were cataloged for a retrospective analysis. The implanted transcatheter valves were Medtronic Evolut R, Evolut PRO, and Evolut PRO+. Gradients were assessed before and after implantation and after fracturing using transthoracic echocardiogram.

Results: The mean left ventricular ejection fraction of patients who underwent fracturing was 55.04%. The average (SD) peak and mean (SD) transvalvular gradients before the intervention were 68.17 (19.09) mm Hg and 38.98 (14.37) mm Hg, respectively. After ViV-TAVI, the same gradients were reduced to 27.25 (12.27) mm Hg and 15.63 (6.47) mm Hg, respectively. After bioprosthetic valve fracture, the gradients further decreased to 17.59 (7.93) mm Hg and 8.860 (3.334) mm Hg, respectively. The average reduction in peak gradient associated with fracturing was 12.07 mm Hg (95% CI, 5.73-18.41 mm Hg; P = .001). The average reduction in mean gradient associated with valve fracturing was 6.97 mm Hg (95% CI, 3.99-9.74 mm Hg; P < .001).

Conclusion: Bioprosthetic valve fracture is a viable option for reducing residual transvalvular gradients after ViV-TAVI and should be considered in patients with elevated gradients (>20 mm Hg) or with concern for patient-prosthesis mismatch in patients who have an unacceptable risk for a redo sternotomy and surgical aortic valve replacement.

Keywords: Transcatheter aortic valve replacement; balloon valvuloplasty; heart valve prosthesis.

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Conflict of interest statement

Conflict of Interest Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein.

Figures

Fig. 1
Fig. 1
Effects of post–ViV-TAVI bioprosthetic valve fracturing on mean transvalvular gradient are shown. The mean (SD) transvalvular gradient before ViV-TAVI was 38.98 (14.37) mm Hg. After ViV-TAVI, the mean (SD) gradient was reduced to 14.159 (5.95) mm Hg. After ViV-TAVI with fracturing, the mean (SD) gradient was further reduced to 8.860 (3.334) mm Hg. The average reduction in mean pressure gradient associated with fracturing was 5.136 mm Hg (95% CI, 2.768-7.505 mm Hg; P < .001). P < .05 was considered statistically significant. ViV, valve-in-valve.
Fig. 2
Fig. 2
Cinefluoroscopy images of surgical valve valvuloplasty show (A) the initial inflation of a valvuloplasty balloon after ViV-TAVI, with notable balloon “waisting” that suggests that the original surgical valve was not fractured or modified sufficiently, and (B) a fully expanded valvuloplasty balloon with a fractured surgical valve ring after ViV-TAVI with bioprosthetic valve fracture. TAVI, transcatheter aortic valve implantation; ViV, valve-in-valve.
See this image and copyright information in PMC

References

    1. Thourani VH, Suri RM, Gunter RL, et al. Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients. Ann Thorac Surg. 2015;99(1):55–61. doi: 10.1016/j.athoracsur.2014.06.050. doi: - DOI - PubMed
    1. Isaacs AJ, Shuhaiber J, Salemi A, Isom OW, Sedrakyan A. National trends in utilization and in-hospital outcomes of mechanical versus bioprosthetic aortic valve replacements. J Thorac Cardiovasc Surg. 2015;149(5):1262–1269.e3. doi: 10.1016/j.jtcvs.2015.01.052. doi: - DOI - PubMed
    1. Brennan JM, Edwards FH, Zhao Y, et al. DEcIDE AVR (Developing Evidence to Inform Decisions about Effectiveness–Aortic Valve Replacement) Research Team. Long-term safety and effectiveness of mechanical versus biologic aortic valve prostheses in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. Circulation. 2013;127(16):1647–1655. doi: 10.1161/CIRCULATIONAHA.113.002003. doi: - DOI - PubMed
    1. Onorati F, Biancari F, De Feo M, et al. Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multicentre European RECORD (REdo Cardiac Operation Research Database) initiative. Eur J Cardiothorac Surg. 2015;47(2):269–280. doi: 10.1093/ejcts/ezu116. doi: - DOI - PubMed
    1. Maganti M, Rao V, Armstrong S, Feindel CM, Scully HE, David TE. Redo valvular surgery in elderly patients. Ann Thorac Surg. 2009;87(2):521–525. doi: 10.1016/j.athoracsur.2008.09.030. doi: - DOI - PubMed

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