Bioprosthetic Valve Fracture for Early Severe Prosthesis Mismatch After SAVR

Patient prosthesis mismatch (PPM) is an iatrogenic complication that occurs in patients who undergo surgical aortic valve replacement (SAVR). PPM occurs when the implanted surgical valve has an effective orifice area (EOA) that is too small for the patient, resulting in a gradient across the valve despite an otherwise normally functioning prosthesis. PPM has been associated with mid- and long-term increased morbidity and mortality. When this occurs, repeat SAVR with root enlargement and implantation of a larger prosthesis is traditionally employed; however, this approach involves the risks of morbidity and mortality of redo surgery, which may be prohibitive in critically ill or medically complex patients. Bioprosthetic valve fracture (BVF), where high-pressure balloon inflation is employed to fracture the surgical valve sewing ring to increase the EOA, has been used as an adjunct for valve-in-valve (transcatheter aortic valve in surgical aortic valve [TAV in SAV]) procedures for degenerated surgical valves to increase EOA, but has not yet been reported as standalone therapy for early PPM after SAVR.

We present a case of a 41-year-old male (body surface area, 2.3 m²) who presented 4 months after SAVR with a 21 mm surgical valve (Magna Ease, true inner diameter, 19 mm) with severe PPM (mean gradient, 43 mm Hg) despite normal functioning valvular prosthetic leaflets, associated with debilitating symptoms. This patient was deemed high risk by the heart team, and was successfully treated with TAV in SAV (26 mm Evolut R) and concomitant high-pressure bioprosthetic valve fracture (BVF) with a 22 mm high-pressure balloon. The patient tolerated the procedure well; mean gradient was 5 mm Hg post BVF and prompt resolution of symptoms was seen. His postprocedure recovery was uneventful and his symptoms resolved, allowing him to return to work within a week of his hospital discharge. BVF associated with TAV in SAV appears to be a feasible approach for treatment of severe symptomatic PPM even in the early postoperative period with otherwise normally functioning prosthesis.