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Keith B. Allen, MD, Adnan K. Chhatriwalla, MD, David J

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Presentation on theme: "Keith B. Allen, MD, Adnan K. Chhatriwalla, MD, David J"— Presentation transcript:

1 Bioprosthetic Valve Fracture to Facilitate Transcatheter Valve-in-Valve Implantation 
Keith B. Allen, MD, Adnan K. Chhatriwalla, MD, David J. Cohen, MD, MS, John T. Saxon, MD, Sanjeev Aggarwal, MD, Anthony Hart, MD, Suzanne Baron, MD, MS, J. Russell Davis, MD, Alex F. Pak, MD, Danny Dvir, MD, A. Michael Borkon, MD  The Annals of Thoracic Surgery  Volume 104, Issue 5, Pages (November 2017) DOI: /j.athoracsur Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2 Fig 1 (A) High-pressure balloon (HPB) inflation was performed with a single-balloon technique. Balloon size was 1 mm larger than the labeled surgical valve size. If HPB inflation with a single balloon did not result in valve ring fracture, then an additional attempt was made using (B) a “kissing” double balloon technique with two Dorado balloons (C.R. Bard, Murray Hill, NJ) whose combined diameter was 1 mm larger than the labeled valve size. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3 Fig 2 (A) Initial setup for high-pressure balloon (HPB) inflation consists of a large syringe, indeflator, and high-pressure tubing and stop cock. (B) The HPB is rapidly filled with a syringe (1) and then the stopcock (2) is turned to allow the indeflator to further pressurize the balloon to desired atmospheres. Successful valve fracture is characterized by a sudden drop in the pressure on the indeflator gauge and often accompanied by an audible snap. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4 Fig 3 Summary of bench testing of high pressure balloon inflation to fracture the valve frame of commercial US surgical tissue valves. (ATM = atmospheres; TRU = Tru Dilation.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

5 Fig 4 A fractured 21-mm Mitroflow (Sorin, Milan, Italy). The Dacron sewing cuff has been partially removed, demonstrating the clean fracture site in the plastic sewing ring (X). Note that the radiopaque cloth strip (white arrow) remains intact after valve fracture and prevents fluoroscopy from documenting valve fracture (insert). The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

6 Fig 5 Fully expanded 23-mm Evolut R (Medtronic Inc, Minneapolis, MN) with manufacturer’s measurements (A). After deployment of a 23-mm Evolut R in an intact 21-mm Magna (Edwards Lifesciences, Irving, CA), the transcatheter valve is constrained, as viewed from (B) below and (C) above, with mildly distorted leaflets and (D) only expands to 19 mm, which is the true internal diameter of surgical valve. After deployment of the 23-mm Evolut R valve in a fractured 21-mm Magna valve, the leaflet coaptation, as viewed from (E) above and (F) below, appears normal and (G) the transcatheter valve appears optimally deployed at 22.9. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

7 Fig 6 (A) Fully expanded 23-mm Sapien XT (Edwards Lifesciences, Irving, CA) with manufacturer’s measurements. (B) After deployment of the 23-mm Sapien XT in an intact 21-mm Magna (Edwards Lifesciences), the transcatheter valve is constrained and only expands to 19.1 mm. (C) After deployment of the 23-mm Sapien XT in a fractured 21-mm Magna surgical valve using only the device delivery balloon, the transcatheter valve remained slightly underdeployed at 22.3 mm. (D) Optimal expansion to 23-mm was only accomplished after postdilating the valve using a 24-mm noncompliant balloon with high pressure inflation. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

8 Fig 7 Computed tomography without contrast of the chest 1-month after VIV TAVR with surgical valve fracture demonstrates a fully expanded transcatheter valve within the fractured valve ring. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

9 Fig 8 (A) When using a high-pressure balloon larger than the constrained area of a self-expanding transcatheter valve, (B) keeping the shoulder of the balloon below the constrained area appears to mitigate the risk of tearing the leaflets and creating aortic insufficiency. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

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