Practical Approach to Transcatheter Aortic Valve Implantation and Bioprosthetic Valve Fracture in a Failed Bioprosthetic Surgical Valve

Figure 4

ViV-TAVI with bioprosthetic valve fracture and suboptimal result in a transfemoral (a–c) and good result in a transapical (d–f) approach. (a) In the 91-year-old female patient from Figure 3, because of low coronary height, anticipated bioprosthetic valve fracture, and shallow sinuses, coronary protection was obtained using a 6 F guiding catheter, 6 F GuideLiner, and undeployed stent standby (yellow arrowhead). A 23 mm Evolut R valve was implanted 4 mm under the fluoroscopic ring of the Epic valve as a reference. (b) Invasive gradient after valve implantation was 26 mmHg. BVF was attempted using an 18 mm True balloon at 14 atm. (c) No change in surgical ring geometry or pressure drop on the indeflator was noticed, but the invasive gradient at the end of the procedure was only 3 mmHg. However, the noninvasive peak transvalvular gradient increased to 60 mmHg at 3 months after TAVI, and the patient was rehospitalized with heart failure. Potentially, the 18 mm balloon (true ID + 1 mm) was slightly undersized to achieve fracturing. (d) In contrast, an 85-year-old patient with extensive peripheral vascular disease and a degenerated Perimount Magna Ease 21 mm valve (true ID: 19 mm) underwent transapical implantation of a 23 mm Sapien 3 valve. Postimplantation invasive gradient was 25 mmHg. (e) Postdilatation with Atlas Gold 22 mm balloon. (f) Sudden geometric expansion of the valve at the end of the inflation and a pressure drop on the indeflator, with a reduction of the gradient to 9 mmHg (circles in (e) and (f) denote the similar region in video 1).

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