Fracturing a dysfunctional Edwards Perimount bioprosthetic valve to facilitate percutaneous valve‐in‐valve placement of SAPIEN 3 valve with modified delivery system

Abstract

Pulmonary valve replacement via surgical implantation of a bioprosthetic valve (BPV) is a wellestablished treatment for patients with dysfunctional RV outflow tracts. BPVs are prone to structural deterioration, and will eventually require replacement. Recently, percutaneous valve-in-valve (VIV) placement of transcatheter valves has established itself as a safe and effective alternative to surgical revision. Unfortunately, VIV therapy is inherently limited by the inner diameter of the BPV, which restricts the number of eligible patients. Other centers have reported on the feasibility of cracking certain BPVs with ultra high-pressure balloons in bench testing. We now report cracking an Edwards Perimount BPV in the pulmonary position to facilitate VIV placement of an Edwards SAPIEN 3. The ability to crack the Perimount valve allowed placement of a larger valve than previously considered and minimized the final valve gradient. In an effort to avoid the morbidity and mortality of surgical pulmonary valve replacement, this new strategy will expand the number of patients eligible for percutaneous VIV therapy.

Valve‐in‐valve‐in‐valve: Balloon expandable transcatheter heart valve in failing self‐expandable transcatheter heart valve in deteriorated surgical bioprosthesis

“…This again emphasizes the need for cautious THV placement during ViV procedures, although a SE device with supra‐annular valve function was indicated in this particularly small bioprosthesis to aim for optimal hemodynamics and initial ViV placement was assessed as adequate without any resheathing or repositioning . Second, intentional fracture of the surgical bioprosthetic stent, which was described before for ViV procedures, is also feasible in an existing ViV configuration. When performing stent fracturing in such cases, recoil of the THV stent should be anticipated and prudent evaluation of hemodynamics and stent behavior should be performed to estimate durability of initial results.…”

Interventional Cardiology for Congenital Heart Disease

“…Growing experience with the procedure has lead to reports describing mounting of the pre-stent onto the valve system reducing the steps required for successful valve implantation, 45) and extension to patients with smaller RV-PA conduits and bioprsothetic valves. 46) 47) Limitations due to valve size in patients with dilated native RVOTs have been met with larger-diameter balloon expandable systems, 48) with simplification of the technique in these patients obviating the need for pre-stenting ( Figure 3 ). Many dysfunctional RVOT's however remain too large for current balloon expandable systems and clinical experience with a number of self-expanding systems have been reported.…”

The snared wire technique for Sapien valve implantation in the pulmonary position

“…The delivery system of the Melody valve is generally accepted as a user‐friendly system and was specifically designed for pulmonary valve replacement. Conversely, the Sapien delivery system was designed for aortic valve replacement and has proven to be challenging for TPVR, as detailed in several reports which describe different techniques to overcome these difficulties 5‐11 …”

“…system was designed for aortic valve replacement and has proven to be challenging for TPVR, as detailed in several reports which describe different techniques to overcome these difficulties. [5][6][7][8][9][10][11] Stiff guide wires that provide sufficient support, careful wire shaping and positioning, and most importantly, avoiding the loss of wire position are the mainstays of a successful delivery of any percutaneous valve in the pulmonary position. Excessive traction on the guidewire can lead to the loss of wire position, potentially jeopardizing the procedure.…”