Author + information
- Received August 6, 2018
- Revision received October 4, 2018
- Accepted October 23, 2018
- Published online January 7, 2019.
- Janarthanan Sathananthan, MBChB, MPHa,
- Stephanie Sellers, PhDb,c,
- Aaron M. Barlow, BSc, PhDb,
- Viktória Stanová, Dipl-Ingd,
- Rob Fraser, MSce,
- Stefan Toggweiler, MDf,
- Keith B. Allen, MDg,
- Adnan Chhatriwalla, MDg,
- Dale J. Murdoch, BSc, MBBSa,h,
- Mark Hensey, MB BCh, BAOa,
- Karen Laub,c,
- Abdullah Alkhodair, MDa,
- Danny Dvir, MDi,
- Anita W. Asgar, MDj,
- Anson Cheung, MDa,
- Philipp Blanke, MDa,c,
- Jian Ye, MDa,
- Régis Rieu, PhDd,
- Phillippe Pibarot, DVM, PhDk,
- David Wood, MDa,
- Jonathan Leipsic, MDa,c and
- John G. Webb, MDa,∗ ()
- aCentre for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- bCentre for Heart Lung Innovation, Vancouver, British Columbia, Canada
- cDepartment of Radiology, St. Paul’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada
- dAix-Marseille Univ, IFSTTAR, LBA UMR_T24, Marseille, France
- eViVitro Labs Inc., Victoria, British Columbia, Canada
- fHeart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
- gSaint Luke’s Hospital, St. Luke’s Mid America Heart Institute, Kansas City, Missouri
- hUniversity of Queensland, Brisbane, Australia
- iUniversity of Washington, Seattle, Washington
- jMontreal Heart Institute, Montreal, Quebec, Canada
- kQuebec Heart & Lung Institute, Laval University, Quebec, Canada
- ↵∗Address for correspondence:
Dr. John G. Webb, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
Objectives The authors assessed the effect of valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) followed by bioprosthetic valve fracture (BVF), testing different transcatheter heart valve (THV) designs in an ex vivo bench study.
Background Bioprosthetic valve fracture can be performed to improve residual transvalvular gradients following VIV TAVR.
Methods The authors evaluated VIV TAVR and BVF with the SAPIEN 3 (S3) (Edwards Lifesciences, Irvine, California) and ACURATE neo (Boston Scientific Corporation, Natick, Massachusetts) THVs. A 20-mm and 23-mm S3 were deployed in a 19-mm and 21-mm Mitroflow (Sorin Group USA, Arvada, Colorado), respectively. A small ACURATE neo was deployed in both sizes of Mitroflow tested. VIV TAVR samples underwent multimodality imaging, and hydrodynamic evaluation before and after BVF.
Results A high implantation was required to enable full expansion of the upper crown of the ACURATE neo and allow optimal leaflet function. Marked underexpansion of the lower crown of the THV within the surgical valve was also observed. Before BVF, VIV TAVR in the 19-mm Mitroflow had high transvalvular gradients using either THV design (22.0 mm Hg S3, and 19.1 mm Hg ACURATE neo). After BVF, gradients improved and were similar for both THVs (14.2 mm Hg S3, and 13.8 mm Hg ACURATE neo). The effective orifice area increased with BVF from 1.2 to 1.6 cm2 with the S3 and from 1.4 to 1.6 cm2 with the ACURATE neo. Before BVF, VIV TAVR with the ACURATE neo in the 21-mm Mitroflow had lower gradients compared with S3 (11.3 mm Hg vs. 16 mm Hg). However, after BVF valve gradients were similar for both THVs (8.4 mm Hg ACURATE neo vs. 7.8 mm Hg S3). The effective orifice area increased from 1.5 to 2.1 cm2 with the S3 and from 1.8 to 2.2 cm2 with the ACURATE neo.
Conclusions BVF performed after VIV TAVR results in improved residual gradients. Following BVF, residual gradients were similar irrespective of THV design. Use of a small ACURATE neo for VIV TAVR in small (≤21 mm) surgical valves may be associated with challenges in achieving optimum THV position and expansion. BVF could be considered in selected clinical cases.
Dr. Leipsic is supported by a Canadian Research Chair in Advanced CardioPulmonary Imaging. Mr. Fraser is an employee of ViVitro Labs. Dr. Toggweiler has been a consultant and proctor for Boston Scientific and New Valve Technology; and has received an institutional research grant from Boston Scientific. Dr. Allen has received research grants from Edwards Lifesciences, Abbott Vascular, and Medtronic; has been a proctor for and received speaker fees from Edwards Lifesciences and Medtronic; and has been a consultant to Abbott Vascular. Dr. Chhatriwalla is on the Speakers Bureau for and received travel reimbursement from Medtronic, Edwards Lifesciences, and Abbott Vascular; and has been a proctor for Medtronic. Dr. Dvir has been a consultant to Edwards Lifesciences, Medtronic, and St. Jude Medical. Dr. Asgar has been a consultant to and has received research support from Abbott Vascular. Dr. Cheung has been a consultant to Abbott Vascular, Medtronic, and Neovasc. Dr. Blanke has been a consultant to Edwards Lifesciences. Dr. Ye has been a consultant to Edwards Lifesciences. Dr. Pibarot has received funding from Edwards Lifesciences; and is a grant recipient from Medtronic. Dr. Wood has been a consultant to and received grant support from Edwards Lifesciences. Dr. Leipsic has been a consultant to Edwards Lifesciences, Circle Cardiovascular Imaging Inc., and HeartFlow; provides CT core lab services for Edwards Lifesciences, Medtronic, Neovasc, GDS, and Tendyne Holdings, for which no direct compensation is received; has stock options in Circle Cardiovascular Imaging Inc. and HeartFlow; and receives institutional research support from HeartFlow. Dr. Webb is a consultant to and has received research funding from Edwards Lifesciences, Abbott Vascular, Boston Scientific, and ViVitro Labs. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 6, 2018.
- Revision received October 4, 2018.
- Accepted October 23, 2018.
- 2019 American College of Cardiology Foundation