Timing of bioprosthetic valve fracture in transcatheter valve- in-valve intervention: impact on valve durability and leaflet integrity

Background: Bioprosthetic valve fracture (BVF) can be used to improve transcatheter heart valve (THV) haemodynamics following a valve-in-valve (ViV) intervention. However, whether BVF should be per-formed before or after THV deployment and the implications on durability are unknown. Aims: We sought to assess the impact of BVF timing on long-term THV durability. Methods: The impact of BVF timing was assessed using small ACURATE neo (ACn) or 23 mm SAPIEN 3 (S3) THV deployed in 21 mm Mitroflow valves compared to no-BVF controls. Valves underwent accel-erated wear testing up to 200 million (M) cycles (equivalent to 5 years). At 200M cycles, THV were evaluated by hydrodynamic testing, second-harmonic generation (SHG) microscopy, scanning electron microscopy (SEM) and histology. Results: At 200M cycles, the regurgitant fraction (RF) and effective orifice area (EOA) for the ACn were 8.03 +/- 0.30%/1.74 +/- 0.01 cm2 (no BVF), 12.48 +/- 0.70%/1.97 +/- 0.02 cm2 (BVF before ViV) and 9.29 +/- 0.38%/2.21 +/- 0.0 cm2 (BVF after ViV), respectively. For the S3 these values were 2.63 +/- 0.51%/1.26 +/- 0.01 cm2, 2.03 +/- 0.42%/1.65 +/- 0.01 cm2, and 1.62 +/- 0.38%/2.22 +/- 0.01 cm2, respectively. Further, SHG and SEM revealed a higher degree of superficial leaflet damage when BVF was performed after ViV for the ACn and S3. However, the histological analysis revealed significantly less damage, as determined by matrix density analysis, through the entire leaflet thickness when BVF was performed after ViV with the S3 and a similar but non-significant trend with the ACn. Conclusions: BVF performed after ViV appears to offer superior long-term EOA without increased RF. Ultrastructure leaflet analysis reveals that the timing of BVF can differentially impact leaflets, with more superficial damage but greater preservation of overall leaflet structure when BVF is performed after ViV.