Bioprosthetic Valve Fracture After TAVR Complicated by Balloon Rupture

Transcatheter aortic valve replacement in surgical aortic valve is a safe and effective procedure to treat patients with failed bioprosthetic surgical valves at high risk for reoperation. Performing bioprosthetic valve fracture has been shown to improve postprocedural hemodynamics of TAVR in surgical aortic valve replacement. However, specific complications related to valve fracture are becoming more common. (Level of Difficulty: Advanced.)


LEARNING OBJECTIVES
To treat patients with degenerated surgical bioprosthesis and high surgical risk through ViV TAVR, a safe and effective procedure. To safely perform BVF in experienced centers with reduction of high residual gradients following ViV TAVR due to PPM. To avoid PPM at the time of index SAVR, especially in younger patients. To better understand balloon reliability at high pressure during BVF, with the support of further research and experience. Computed tomography demonstrated adequate femoral access for TAVR, valve-to-coronary distance >9 mm, and a Sino-tubular junction diameter of 25 mm (Figures 2 and 3).

MANAGEMENT
The heart team recommended ViV TAVR using a supra-annular self-expandible 23-mm valve. The transaortic valve was rightly implanted through femoral access (Figure 4), but a residual mean transvalvular gradient of 31 mm Hg was documented. The decision was made to perform bioprosthetic valve fracture (BVF). A 22-mm noncompliant balloon was inflated to 26 atm, as recommended for patient's valve type. 2 A visible release of the balloon waist was obtained on fluoroscopy, indicating that the bioprosthetic ring had been fractured. 3 As described in the bench side model, for the patient's valve type, the mechanism of fracture was probably caused by a linear dissection of the outer ring of the bioprosthesis attributable to a single fracture line, the latter not  Surgical bioprosthetic valve degeneration is a well-known condition with reoperation rates of z10% and 30% at 10 and 15 years, respectively. 5  The ViV procedure has emerged as a novel option whereby a transcatheter heart valve (THV) is implanted within a failed surgical heart valve. However, some concerns arise, mostly regarding patient-prosthesis mismatch (PPM), particularly in patients with small bioprosthetic valves (#21 mm) associated with reduced survival. 1 In the VIVID registry, 32% of patients had severe PPM following VIV TAVR, which has been associated with increased long-term mortality following both surgical and THV implantation. 5 BVF emerged as a novel technique to address this problem in targeted types of surgical bioprosthesis.
According to the bench tests, the BVF procedure appears to be effective for sewing ring fracture if a dedicated pressure of inflation is reached. 1 In a large multicenter series, BVF was safely performed along with both balloon and self-expanding THVs, resulting in significantly lower transvalvular gradients and increased EOA. In addition, 1-year follow-up after BVF demonstrates persistent low gradients, no signal  for TAVR injury, and improved survival compared with historical control subjects. 6 As reported by recent metanalysis, after ViV-TAVR performed with BVF, the difference in means for mean valve gradients showed a significant reduction (random-effects model: À26.7; À28.8 to À24.7; P < 0.001), whereas the difference in means for aortic valve area showed a significant increase (randomeffects model: 0.55 cm 2 ; 0.13-0.97; P ¼ 0.029).
However, despite the improvement in aortic valve area means, these remain too low (<1.5 cm 2 ) after the procedure, highly likely caused by the small size of the bioprosthetic valves implanted during the index SAVR. This should be kept in mind, also considering an ever-growing number of patients with obesity.
Even when we change the thresholds for PPM for obese patients, as suggested by some authors, the risk of PPM is very high. 7 Consequently, the index SAVR acquires great importance in avoiding PPM. 8 If surgeons are unable to implant an appropriate valve, they should resort to surgical techniques to enlarge the aortic annulus, making sure that the patient will receive a large valve and will not leave with PPM. 9 Furthermore, it should be kept in mind that PPM is not only caused by the size of the valve chosen during the index SAVR but also ascribed to patient's BSA, and this must be considered on a case-by-case basis. 10 It should also be considered that a series of complications with BVF have been described.
Particularly, a case of balloon rupture without clinical adverse event has been reported. 3   Bioprosthetic Valve Fracture After TAVR Complicated by Balloon Rupture fractured to optimize transcatheter valve expansion is currently being debated.