Interventions for valvular disease and heart failure - Mini-focus on transcatheter aortic valve implantation

Redo-TAVI with SAPIEN 3 in SAPIEN XT or SAPIEN 3 – impact of pre- and post-dilatation on final THV expansion

EuroIntervention 2023;19:757-765. DOI: 10.4244/EIJ-D-23-00308

David Meier
David Meier1,2,3, MD; Uri Landes4,5, MD; Lars Sondergaard6, MD; Ole De Backer7, MD, PhD; Georg Lutter8,9, MD; Thomas Puehler8,9, MD; Mariama Akodad10, MD, PhD; Georgios Tzimas3, MD; Philipp Blanke3, MD; Geoffrey W. Payne11, MSc, PhD; Althea Lai2, BSc; Hacina Gill2, BSc; David A. Wood1,3, MD; John G. Webb1,3, MD; Stephanie L. Sellers1,2,3, MSc, PhD; Janarthanan Sathananthan1,2,3, MPH, MBChB
1. Centre for Cardiovascular Innovation, St Paul’s Hospital, Vancouver, BC, Canada and Vancouver General Hospital, Vancouver, BC, Canada; 2. Cardiovascular Translational Laboratory, Vancouver, BC, Canada and Providence Research & Centre for Heart Lung Innovation, Vancouver, BC, Canada; 3. Centre for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada; 4. Edith Wolfson Medical Center, Holon, Israel; 5. Rabin Medical Center, Petah Tikva, Israel and Tel Aviv University, Tel Aviv, Israel; 6. Abbott Structural Heart, Santa Clara, CA, USA; 7. Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; 8. DZHK (German Centre for Cardiovascular Research), partner site Kiel/Hamburg/Lübeck, Kiel Germany; 9. Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holsten, Campus Kiel, Kiel, Germany; 10. Institut Cardiovasculaire Paris Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay Santé, Massy, France; 11. University of Northern British Columbia, Prince George, BC, Canada

Background: When a balloon-expandable transcatheter heart valve (THV) is chosen to treat a failed balloon-expandable THV, there is a risk of underexpansion with a potential impact on performance.

Aims: We aimed to assess the impact of pre- and post-dilatation on the expansion of balloon-expandable THVs after redo-transcatheter aortic valve implantation (TAVI).

Methods: Redo-TAVI was performed on the bench with a 23 mm SAPIEN 3 (S3) implanted within a 23 mm SAPIEN XT (SXT) or a 23 mm S3, both of which served as the “failed” THVs. Pre- and/or post-dilatation was performed using a 23 mm non-compliant TRUE balloon. Expansion of the index and redo-THVs were assessed before and after pre-/post-dilatation using microcomputed tomography (micro-CT), and THV hydrodynamic testing was conducted.

Results: Without pre- or post-dilatation, the S3 was underexpanded, for all combinations, particularly in the mid-portion of the THV (18.6 mm and 19.7 mm representing 81% and 86% of the nominal diameter inside the SXT and S3, respectively). Pre- and post-dilatation had an additive effect on diameter expansion of the redo-THV, which remained constrained in most combinations. The only combination to achieve nominal expansion was the S3 in S3 when both pre- and post-dilatation were performed. The S3 remained underexpanded inside the SXT despite pre- and post-dilatation (93% in the mid-portion). Improved redo-THV expansion was accompanied by 2.7 mm (12%) overexpansion of the index THV. While all samples had acceptable hydrodynamic performance, the underexpanded samples had worse leaflet pinwheeling.

Conclusions: When performing redo-TAVI with a 23 mm S3 inside a 23 mm SXT or S3, only the S3 in S3 with the use of pre- and post-dilatation reached full expansion. This underlines the importance of CT assessment of THV expansion and the role of pre-/post-dilatation.

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