Hemodynamic Durability of Bioprosthetic Valve Fracture for Valve in Valve TAVR

Background
Valve in valve transcatheter aortic valve replacement (VIV TAVR) in failed surgical bioprostheses may be limited by patient-prosthesis mismatch, which has been associated with reduced survival at 1 year. Bioprosthetic valve fracture (BVF) at the time of VIV TAVR is a safe and effective method to improve procedural hemodynamics, yet the durability of the hemodynamic results of this approach is unknown.

Methods
BVF was performed as an adjunct to VIV TAVR in accordance with previously published methods. Intraprocedural hemodynamics, 1-month and 1-year echocardiographic follow-up data were collected. Mean transvalvular gradients were compared using paired t-tests.

Results

Data from 17 consecutive patients who underwent BVF and VIV TAVR at 5 centers and who underwent 1-month and 1-year echocardiograms were analyzed. Mean age was 75.1 years and mean STS PROM was 6.6%. The mean labeled surgical valve size was 21.5± 1.9 mm, corresponding to a mean true inner diameter of 18.5± 1.9 mm. BVF was performed after TAVR in 82% (14/17) of cases. Survival at 1 year was 100%. Hemodynamics are displayed in Figure 1. Baseline mean transvalvular gradient and aortic valve area (AVA) were 43± 19 mmHg and 0.8± 0.3 cm², respectively, which improved to 11± 8 mmHg and 2.1± 0.7 cm² following VIV TAVR and BVF (p<0.001 for both comparisons). The mean transvalvular gradient was 13± 6 mmHg at 1 month 14± 8 mmHg at 1 year (p=NS vs. immediate post-procedure for both comparisons).

Conclusions
The immediate hemodynamic results of BVF to facilitate VIV TAVR are favorable and appear durable at 1 month and 1 year. Further investigation is needed to assess long-term clinical outcomes of BVF and VIV TAVR.