The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

Bioprosthetic valve fracture performed before versus after valve-in-valve intervention: Insights from bench testing

DOI: 10.4244/EIJ-D-19-00939

1. Centre for Heart Valve Innovation, St Paul's Hospital, University or British Columbia, Vancouver, Canada, Canada
2. ViVitro Labs Inc, Victoria, Canada
3. Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio
4. Centre for Heart Lung Innovation, Vancouver, Canada
5. Aix-Marseille Univ, IFSTTAR, LBA UMR_T24, Marseille, France
6. Saint Luke’s Hospital, St. Luke’s Mid America Heart Institute, Kansas City, MO, USA
7. Quebec Heart & Lung Institute, Laval University, Quebec, Canada
8. Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
9. Centre for Heart Valve Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, Canada
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Aims:  Bioprosthetic valve fracture(BVF) may improve transvalvular gradients and transcatheter heart valve(THV) expansion during VIV interventions. However, the optimal timing of BVF is unknown. We assessed the impact of timing of BVF for valve-in-valve(VIV) intervention, on hydrodynamic function and THV expansion.

Methods and results: Three THV designs were assessed, a 23mm SAPIEN 3(S3), small ACURATE neo(ACn) and 23mm Evolut R, deployed into 21mm Mitroflow bioprosthetic surgical valves. We evaluated each THV in three groups: 1)No BVF, 2)BVF before VIV and 3)BVF after VIV. Hydrodynamic testing was performed using a pulse duplicator to ISO 5840:2013 standard. Transvalvular gradients were lower when BVF was performed after VIV for the S3(No BVF 15.5mmHg, BVF before VIV 8.0mmHg, BVF after VIV 5.6mmHg), and the ACn(No BVF 9.8mmHg, BVF before VIV 8.4mmHg, BVF after VIV 5.1mmHg). Transvalvular gradients were similar for the Evolut R, irrespective of performance of BVF or timing of BVF. BVF performed after VIV resulted in better expansion in all three THV designs. The ACn and Evolut R samples all had a mild degree of pinwheeling, and BVF timing did not impact pinwheeling severity. The S3 samples had severe pinwheeling with no BVF, and significant improvement in pinwheeling when BVF was performed after VIV. 

Conclusions: BVF performed after VIV was associated with superior THV expansion in all three tested THVs designs, with lower residual transvalvular gradients in the S3 and ACn THVs. The Evolut R had similar hydrodynamic performance irrespective of BVF timing. Timing of BVF has potential implications on THV function.

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