Keith B Allen1, Adnan K Chhatriwalla2, John T Saxon2, David J Cohen2, Tom C Nguyen3, John Webb4, Pranav Loyalka4, Anthony A Bavry5, Joshua D Rovin6, Brian Whisenant7, Danny Dvir4, Kevin F Kennedy2, Vinod Thourani8, Richard Lee9. 1. Department of Cardiothoracic Surgery, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, Mo. Electronic address: kallen2340@aol.com. 2. Department of Cardiology, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, Mo. 3. Department of Cardiology, University of Texas Medical School at Houston, Houston, Tex. 4. Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada. 5. Department of Cardiology, University of Florida, Gainesville, Fla. 6. Department of Cardiothoracic Surgery, Morton Plant Hospital, Tampa Bay, Fla. 7. Department of Cardiology, Intermountain Heart Institute, Murry, Utah. 8. Department of Cardiothoracic Surgery, MedStar Heart and Vascular Institute/Georgetown University School of Medicine, Washington, DC. 9. Department of Cardiothoracic Surgery, Saint Louis University School of Medicine, Saint Louis, Mo.
Abstract
OBJECTIVE: Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) can result in high residual gradients that are associated with increased mortality. Bioprosthetic valve fracture (BVF) has been shown to improve residual gradients following VIV TAVR; however, factors influencing the results of BVF have not been studied. METHODS: BVF was performed in 75 patients at 21 centers. Hierarchical multiple linear regression was performed to identify variables that were associated with lower final transvalvular gradient. RESULTS: Surgical valves with a median true internal diameter of 18.5 mm (interquartile range, 17.0-20.5 mm) were treated with VIV TAVR in conjunction with BVF using balloon-expandable (n = 43) or self-expanding (n = 32) transcatheter heart valves with a median size of 23 mm (interquartile range, 23-23 mm). There were no aortic root disruptions, coronary occlusions, or new pacemakers; in-hospital or 30-day mortality was 2.6% (2 out of 75). Final mean transvalvular gradient was 9.2 ± 6.3 mm Hg, but was significantly lower when BVF was performed after VIV TAVR compared with BVF first (8.1 ± 4.8 mm Hg vs 16.9 ± 10.1 mm Hg; P < .001). After adjusting for timing of BVF (ie, before or after VIV TAVR), transcatheter heart valve size/type, surgical valve mode of failure, true internal diameter, and baseline gradient and BVF balloon size, performing BVF after VIV TAVR (P < .001) and using a larger BVF balloon (P = .038) were the only independent predictors of lower final mean gradient. CONCLUSIONS: BVF can be performed safely and results in reduced residual transvalvular gradients. Performing BVF after VIV TAVR and using larger balloon appears to achieve the best hemodynamic results.
OBJECTIVE: Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) can result in high residual gradients that are associated with increased mortality. Bioprosthetic valve fracture (BVF) has been shown to improve residual gradients following VIV TAVR; however, factors influencing the results of BVF have not been studied. METHODS: BVF was performed in 75 patients at 21 centers. Hierarchical multiple linear regression was performed to identify variables that were associated with lower final transvalvular gradient. RESULTS: Surgical valves with a median true internal diameter of 18.5 mm (interquartile range, 17.0-20.5 mm) were treated with VIV TAVR in conjunction with BVF using balloon-expandable (n = 43) or self-expanding (n = 32) transcatheter heart valves with a median size of 23 mm (interquartile range, 23-23 mm). There were no aortic root disruptions, coronary occlusions, or new pacemakers; in-hospital or 30-day mortality was 2.6% (2 out of 75). Final mean transvalvular gradient was 9.2 ± 6.3 mm Hg, but was significantly lower when BVF was performed after VIV TAVR compared with BVF first (8.1 ± 4.8 mm Hg vs 16.9 ± 10.1 mm Hg; P < .001). After adjusting for timing of BVF (ie, before or after VIV TAVR), transcatheter heart valve size/type, surgical valve mode of failure, true internal diameter, and baseline gradient and BVF balloon size, performing BVF after VIV TAVR (P < .001) and using a larger BVF balloon (P = .038) were the only independent predictors of lower final mean gradient. CONCLUSIONS: BVF can be performed safely and results in reduced residual transvalvular gradients. Performing BVF after VIV TAVR and using larger balloon appears to achieve the best hemodynamic results.
Authors: Andrea Buono; Diego Maffeo; Giovanni Troise; Francesco Donatelli; Maurizio Tespili; Alfonso Ielasi Journal: J Clin Med Date: 2022-01-11 Impact factor: 4.241