Bioprosthetic Valve Fracture to Facilitate Transcatheter Valve-in-Valve Implantation

Abstract

Bench testing demonstrates that the frame of most, but not all, bioprosthetic surgical aortic valves can be fractured using high-pressure balloons. The safety of bioprosthetic valve fracture to optimize valve-in-valve transcatheter aortic valve replacement in small surgical valves requires further clinical investigation.

Transcatheter Aortic and Mitral Valve‐in‐Valve Implantation Using the Edwards Sapien 3 Heart Valve

“…As a result, a preprocedural evaluation of the EOA may be particularly important to determine appropriate clinical management and THV implantation strategy; however, in selected cases the benefit of acute gradient reduction and hemodynamic improvement in highly symptomatic patients at prohibitive risk of re‐do surgery may, nevertheless, outweigh the risk of PPM that can occur after a VIV procedure. More recently, deliberate bioprosthetic sewing ring fracture (discussed below) using high‐pressure balloon dilatation (“cracking‐the‐ring”) has emerged as a promising adjunct for aortic VIV in a small bioprosthesis in order to facilitate implantation of a larger THV size and effectively reduce postprocedural gradients 27, 28…”

“…Controlled cracking of the polyester loop within the valve sewing ring using high‐pressure balloons has been described in vitro and in a small number of in vivo cases for surgical valves implanted in the pulmonary position40 with meaningful reductions in postprocedural gradient. In vitro, the frames of the Mitroflow, Magna, Magna Ease, and Mosaic,27 plus the Biocor Epic and Perimount40 bioprosthetic surgical valves have been successfully fractured using high‐pressure True Dilatation and Atlas Gold balloons (Bard Peripheral Vascular). Balloon‐rated burst pressure was exceeded in all cases and fracture of valves with metal sewing rings was not possible.…”

“…The latter approach reduces the risk of acute valvular insufficiency but may increase the difficulty in achieving ring fracture and the risk of injuring the THV leaflets. In most cases our preference is to perform high‐pressure balloon dilatation after implantation of the THV; however, this novel technique may also be associated with an elevated risk of embolization of degenerated valve material, rupture of the aortic root, coronary obstruction, and heart block 27, 28…”

Transcatheter aortic valve replacement in failed surgical valves

“…The technique employs non-compliant balloons such as the Atlas Gold (BARD Peripheral Vascular, Tempe, Arizona, USA) and the TRUE Balloon (BARD Peripheral Vascular) that are commonly sized 1 mm above the label size 27. Not all surgical valve rings are amenable to cracking, but in vitro analyses have identified which devices can be cracked and what pressure in atmospheres is required 28. The risks and benefits of BVF will be further studied and in the future clearer recommendations on how and when to use this technique will be provided.…”

2018 AATS/ACC/SCAI/STS expert consensus systems of care document: Operator and institutional recommendations and requirements for transcatheter aortic valve replacement

“…The evolution of ViV deployment of TAVR prostheses offers an alternative approach to dealing with tissue valve degeneration, although the operative risk reported with open reoperation is low . Recently, the use of high‐pressure balloons to fracture failed surgical implants to facilitate larger TAVR implants has been described . The ViV option has important implications for planning the initial implant, including favoring larger prostheses to minimize the anticipated gradient after ViV deployment.…”