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.
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%.
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.
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).
Conclusion
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.
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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