When Is It Best to Fracture a Bioprosthesis in TAVR?

At present, surgical aortic valve replacement (SAVR) uses bioprostheses. However, when these fail, we are presented with a great challenge, seeing as repeat SAVR involves a higher risk. In this context, valve-in-valve (V-in-V TAVR) has surged as a very attractive alternative. 

¿Cuándo es el mejor momento para realizar una fractura de la bioprótesis en el TAVI?

Bioprosthesis fracture (BPF) is a new interesting strategy that has shown lower gradient and larger effective orifice area (especially in small valves). However, it still involves certain risk. 

This analysis looked at STS/ACC registry V-in-V patients treated with SAPIEN 3 or SAPIEN ULTRA undergoing BPF before or after V-in-V TAVR. 

2975 patients were included, and 619 received BPF before or after TAVR (20.8%).

There were no differences between groups. Mean age was 73, 70% were men, 82% were hypertensive, 32% diabetic, 14% had prior pacemaker, and 65 ml/min eGFR. Prior CABG, cardiac failure and cardiogenic shock was higher among patients not receiving BPF. 

STS Score was 5.3%.

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95% pr procedures were transfemoral, implantation success rate was 99%, and SAPIEN 3 was used most often (84%).

BPF was more frequent after TAVR (75%); 23% was done before TAVR and 2% before and after TAVR. BPF was successful in 512 patients (83%), and it was more frequent in patients with 21 mm bioprosthesis (30% vs.15% p<0.01).

At hospital level, patients receiving BPF presented higher all-cause mortality (2.26 0.91 2.51 1.3-4.84 p<0.01) and life threatening bleeding 3.39 (1.36 2.55 (1.44-4.5) <0.01), with no differences as regards vascular complications, stroke, definite pacemaker implantation, atrial fibrillation, heart obstruction, ring fracture, dialysis, aortic dissection and cardiac piercing. 

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At 30 days, hemodynamic assessment was carried out by Eco-Doppler, which showed that when BPF was prior V-in-V there were no hemodynamic differences vs. the rest. However, in post V-in-V BPF patients, there was larger effective orifice area (1.6 cm2 vs 1.4 cm2; P < 0.01) and lower gradient (18.3 mm Hg vs 22.6 mm Hg; P < 0.01). 


Bioprosthesis fracture in V-in-V with SAPIEN 3 or SAPIEN ULTRA was associated to high inhospital mortality and bleeding and modest echocardiographic hemodynamic improvement. Appropriate bioprosthesis fracture timing is associated to safety and efficacy. 

Dr. Carlos Fava - Consejo Editorial SOLACI

Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.

Original Title: Outcomes of Bioprosthetic Valve  Fracture in Patients Undergoing Valve-in-Valve TAVR. 

Reference: Adnan K. Chhatriwalla, et al. J Am Coll Cardiol Intv 2023;16:530–539).

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