Updates on bioprosthetic valve fracture

ABSTRACT

Introduction

Valve-in-valve (VIV) transcatheter valve replacement has emerged as a feasible and potentially safer treatment option for failed bioprosthetic surgical valves (BSVs). However, the VIV procedure carries an inherent risk of prosthesis-patient mismatch (PPM). Bioprosthetic valve fracture (BVF) and bioprosthetic valve remodeling (BVR) by either fracturing or stretching the surgical valve ring allows for a more optimal expansion of the transcatheter heart valve (THV) and beneficial effects on post-implant valve hemodynamics and perhaps long-term valve durability.

Areas covered

This is an expanded overview of BVF and BVR to facilitate VIV transcatheter aortic valve replacement (TAVR), with detailed discussion on lessons learned from bench testing studies and translation to procedural technique and clinical experience incorporating up-to-date evidence and experience with BVF in non-aortic positions.

Expert opinion

BVF and BVR improve valve hemodynamics following VIV-TAVR, with timing of BVF being an important determinant of procedure safety and efficacy; however, longer-term data are needed to determine long-term clinical outcomes including mortality, valve hemodynamics, and valve reintervention. In addition, further research will be needed to understand the safety and efficacy of these procedures in any new generation BSV or THV and to better define the role of these techniques in the pulmonic, mitral, and tricuspid positions.

KEYWORDS:

• Bioprosthetic valve fracture
• bioprosthetic valve remodeling
• prosthesis-patient mismatch
• valve-in-valve
• transcatheter aortic valve replacement
• transcatheter pulmonary valve replacement
• transcatheter mitral valve replacement

Article highlights

• PPM is a concern during transcatheter valve-in-valve procedures and is associated with increased morbidity and mortality.

• Many surgical valves can be fractured with a high-pressure balloon inflation to optimize THV expansion, while others can be remodeled or stretched, and some cannot be modified at all.

• BVF and BVR have been shown to improve valve hemodynamics following transcatheter VIV procedures.

• BVF and BVR have the potential to improve THV durability by optimizing valve frame expansion and leaflet motion.

• Further research is needed to characterize the risks of BVF/BVR, their impact on morbidity, mortality, and valve durability, and optimal techniques for performing these procedures.

Declaration of interest

AK Chhatriwalla has received speakers bureau from Boston Scientific, Proctor and Medtronic Inc., and research grants from Edwards Lifesciences. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.