Fracturing mechanics before valve-in-valve therapy of small aortic bioprosthetic heart valves.

AIMS Patients with degraded bioprosthetic heart valves (BHV) who are not candidates for valve replacement may benefit from transcatheter valve-in-valve (VIV) therapy. However, in smaller-sized surgical BHV the resultant orifice may become too narrow. To overcome this, the valve frame can be fractured by a high-pressure balloon prior to VIV. However, knowledge on fracture pressures and mechanics are prerequisites. The aim of this study was to identify the fracture pressures needed in BHV, and to describe the fracture mechanics. METHODS AND RESULTS Commonly used BHV of small sizes were mounted on a high-pressure balloon situated in a biplane fluoroscopic system with a high-speed camera. The instant of fracture was captured along with the balloon pressure. The valves were inspected for material protrusion and later dissected for fracture zone investigation and description. The valves with a polymer frame fractured at a lower pressure (8-10 atm) than those with a metal stent (19-26 atm). None of the fractured valves had elements protruding. CONCLUSIONS VIV procedures in small-sized BHV may be performed after prior fracture of the valve frame by high-pressure balloon dilatation. This study provides tentative guidelines for expected balloon sizes and pressures for valve fracturing.