Bioprosthetic Valve Fracture to Facilitate ViV TAVR: Lessons Learned
Keith B. Allen1, Adnan K. Chhatriwalla1, John T. Saxon1, David J. Cohen1, John Webb2, Vinod Thourani3, Anthony A. Bavry4, Joshua D. Rovin5, Tom C. Nguyen6, Pranav Loyalka6, Brian W. Hummel7, Mark J. Russo8, Richard Lee9, Brian W. Whisenant10, Danny Dvir2
1Saint Luke's Mid America Heart Institute, Kansas City, MO;2University of British Columbia, Vancouver, BC, Canada3MedStar Washington Hospital Center, Washington DC, DC;4University of Florida, Gainesville, FL;5Morton Plant Hospital, Tampa Bay, FL;6University of Texas School of Medicine at Houston, Houston, TX;7Lee Memorial Hospital, Fort Myers, FL;8Newark Beth Israel Medical Center, Newark, NJ;9Saint Louis University School of Medicine, Saint Louis, MO;10Intermountain Heart Institute, Murry, UT
OBJECTIVES: Valve-in-Valve transcatheter aortic valve replacement (VIV-TAVR) in small surgical bioprostheses often 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 high-pressure balloon inflation to facilitate VIV-TAVR.
METHODS: From March 2016 through October 2017 BVF was performed in 56 patients undergoing VIV-TAVR at 16 US centers. Hemodynamic parameters and valve effective orifice area (EOA) at baseline, immediately after VIV-TAVR and after BVF were analyzed.
RESULTS: Median age was 77 (range 21-91) with a median STS PROM of 7.3% (range 2.3-20). Median labeled surgical valve size was 21 mm (range 19-27) with a median true internal diameter of 17 mm (15.5-25). Access was transfemoral (52), transcarotid (2), transcaval (1), and subclavian (1) using both balloon-expandable (n=31) or self-expanding (n=25) transcatheter valves (Figure 1). Etiology of prosthetic valve dysfunction was aortic stenosis (42), aortic insufficiency (8) and mixed (6). Mean baseline prosthetic valve gradient in patients with aortic stenosis was 40.0 + 14.0 mmHg. BVF was performed after VIV TAVR in 49 patients while BVF was performed prior to VIV TAVR in 7 patients. BVF reduced the mean transvalvular gradient following VIV-TAVR from 20.0 + 7.9 mmHg to mean 7.9 + 4.4 mmHg (p<0.001) with an increase in mean valve EOA from 1.1 + 0.8 cm2 to 1.9 + 0.7 cm2 (p<0.001). In hospital/30-day mortality was 1.8% (1/56) with no aortic root disruptions or coronary occlusions and no new permanent pacemaker implants. Complications included non-disabling stroke (2), new moderate mitral regurgitation (1) and transcatheter valve insufficiency requiring 2nd transcatheter valve (2). Final paravalvular aortic insufficiency was either none (n=52) or trivial (n=4).
CONCLUSIONS: BVF to facilitate VIV-TAVR in small surgical valves results in reduced residual gradients and increased EOA. Continued evaluation of this technique is warranted to refine procedural techniques, determine long term clinical outcomes and BVF's effect on transcatheter VIV durability.
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