Bioprosthetic Valve Fracturing in Valve-in-Valve TAVI: Clinical and Echocardiographic Outcomes in Failing Perimount Aortic Bioprostheses—A Multicenter Registry

Background: Data comparing clinical and hemodynamic outcomes of bioprosthetic valve fracturing (BVF) and “standard”-postdilatation during valve-in-valve transcatheter heart valve implantation (ViV-TAVI) are lacking. The authors aimed to analyze hemodynamic and clinical outcomes of BVF compared to “standard”-postdilatation during ViV-TAVI. Methods: The REDUCE registry included patients who underwent ViV-TAVI within a Perimount surgical aortic valve bioprosthesis (Edwards Lifesciences, USA). Procedures were categorized to no postdilatation, “standard”-postdilatation and BVF. Hemodynamic and clinical outcomes at 30 days were collected and compared. A linear regression model was built to predict mean aortic gradient after ViV-TAVI. Results: A total of 240 patients from six European sites were included. Median age was 78 years [IQR 70; 83], logistic EuroSCORE calculated 20.0%[IQR 12.2; 33.1] and 159 patients (66%) were male. One hundred fourty-four Perimount valves (60%) had a true internal diameter (ID) ≤ 21 mm. Self-expanding valves (SEV) and ballon-expandable valves (BEV) were used in 60% and 40% of cases, respectively. One hundred sixteen procedures (48%) were executed without postdilatation, in 88 procedures (37%) “standard”-postdilatation and in 36 procedures (15%) BVF was used. 30-day survival was 93.3%. VARC-3 device success at 30 days was 71%. A multivariable regression analysis of the mean aortic gradient after ViV-TAVI showed a significant association with surgical valve size (−0.84 mmHg, p = 0.001; per 1 mm surgical valve size increase), execution of postdilatation (−3.25 mmHg, p = 0.007) and type of transcatheter heart valve (SEV: −7.31 mmHg, p < 0.001). Conclusions: When performing ViV-TAVI within a Perimount surgical aortic bioprosthesis with a true ID ≤ 21 mm, the hemodynamic valve performance is most optimal when implanting a SEV-TAV and when postdilating the TAV-in-SAV complex. BVF did not result in superior hemodynamics compared to “standard”-postdilatation.