Remodel the Failed Trifecta or Not: That Is a Question

Using a high-pressure balloon to do bioprosthetic valve remodeling (BVR) for a failed surgical non-fracturable aortic valve is thought to improve the expansion of a transcatheter heart valve (THV) during valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). However, the risks and benefits of this approach remain under debate. We present two cases of failed bioprosthetic aortic valves (Trifecta 19 mm and 21 mm, Abbott Vascular) receiving ViV-TAVR using balloon-expandable valves (Sapien 3 20-mm, Edwards Lifesciences). In one patient, an ATLAS GOLD balloon catheter (20 mm, BD, Franklin Lakes, New Jersey, USA) was used to do BVR. In the other patient, a double-tap technique with the same volume balloon post-dilatation was performed without BVR. Both procedures were successful, with notable clinical improvement. The post-TAVR computed tomography and transthoracic echocardiogram were performed 1 month after the procedure which demonstrated comparable hemodynamic results; however, the THV deformation was more pronounced in the patient who underwent BVR. Importantly, the THV-to-coronary ostium distance in this patient decreased unexpectedly from 5 mm to near 0 mm over right coronary artery. These cases illustrate that using a high-pressure balloon to perform BVR in a non-fracturable surgical valve had limited impact on THV expansion at the annular level. Conversely, unpredictable over-expansion of the THV in the outflow portion may pose an increased risk to the coronaries, even when the valve-to-coronary distance is long prior to the valve-in-valve TAVR procedure.