Interventions for valvular disease and heart failure

Timing of bioprosthetic valve fracture in transcatheter valve-in-valve intervention: impact on valve durability and leaflet integrity

EuroIntervention 2023;18:1165-1177. DOI: 10.4244/EIJ-D-22-00644

David Meier
David Meier1,2,3, MD; Geoffrey W. Payne4, MSc, PhD; Leila B. Mostaço-Guidolin5, PhD; Rihab Bouchareb6, MSc, PhD; Courtney Rich7, BASc; Althea Lai2, BSc; Andrew G. Chatfield1,2, MB ChB; Mariama Akodad1,2,3, MD, PhD; Hannah Salcudean2, BSc; Georg Lutter8,9, MD; Thomas Puehler8,9, MD; Philippe Pibarot10, DVM, PhD; Keith B. Allen11, MD; Adnan K. Chhatriwalla11, MD; Lars Sondergaard12, MD; David A. Wood1,3, MD; John G. Webb1,3, MD; Jonathon A. Leipsic3, MD; Janarthanan Sathananthan1,2,3, MBChB, MPH; Stephanie L. Sellers1,2,3, MSc, PhD
1. Centre for Cardiovascular Innovation, St Paul’s and Vancouver General Hospital, Vancouver, BC, Canada; 2. Cardiovascular Translational Laboratory, 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. University of Northern British Columbia, Prince George, BC, Canada; 5. Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada; 6. Icahn School of Medicine at Mount Sinai, New York, NY, USA; 7. ViVitro Labs Inc., Victoria, BC, Canada; 8. Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany; 9. DZHK (German Centre for Cardiovascular Research), partner site Kiel/Hamburg, Hamburg, Germany; 10. Québec Heart and Lung Institute, Department of Medicine, Laval University, Québec, QC, Canada; 11. Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA; 12. Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Background: Bioprosthetic valve fracture (BVF) can be used to improve transcatheter heart valve (THV) haemodynamics following a valve-in-valve (ViV) intervention. However, whether BVF should be performed before or after THV deployment and the implications on durability are unknown. 

Aims: We sought to assess the impact of BVF timing on long-term THV durability.

Methods: The impact of BVF timing was assessed using small ACURATE neo (ACn) or 23 mm SAPIEN 3 (S3) THV deployed in 21 mm Mitroflow valves compared to no-BVF controls. Valves underwent accelerated wear testing up to 200 million (M) cycles (equivalent to 5 years). At 200M cycles, THV were evaluated by hydrodynamic testing, second-harmonic generation (SHG) microscopy, scanning electron microscopy (SEM) and histology.

Results: At 200M cycles, the regurgitant fraction (RF) and effective orifice area (EOA) for the ACn were 8.03±0.30%/1.74±0.01 cm2 (no BVF), 12.48±0.70%/1.97±0.02 cm2 (BVF before ViV) and 9.29±0.38%/2.21±0.0 cm2 (BVF after ViV), respectively. For the S3 these values were 2.63±0.51%/1.26±0.01 cm2, 2.03±0.42%/1.65±0.01 cm2, and 1.62±0.38%/2.22±0.01 cm2, respectively. Further, SHG and SEM revealed a higher degree of superficial leaflet damage when BVF was performed after ViV for the ACn and S3. However, the histological analysis revealed significantly less damage, as determined by matrix density analysis, through the entire leaflet thickness when BVF was performed after ViV with the S3 and a similar but non-significant trend with the ACn. 

Conclusions: BVF performed after ViV appears to offer superior long-term EOA without increased RF. Ultrastructure leaflet analysis reveals that the timing of BVF can differentially impact leaflets, with more superficial damage but greater preservation of overall leaflet structure when BVF is performed after ViV. 

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bench testingtranscatheter valve replacementvalve durabilityvalve fracture
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