Updates on bioprosthetic valve fracture

INTRODUCTION: Valve-in-valve (VIV) transcatheter valve replacement has emerged as a feasible and potentially safer treatment option for failed bioprosthetic surgical valves (BSVs). However, the VIV procedure carries an inherent risk of prosthesis-patient mismatch (PPM). Bioprosthetic valve fracture (BVF) and bioprosthetic valve remodeling (BVR) by either fracturing or stretching the surgical valve ring allows for a more optimal expansion of the transcatheter heart valve (THV) and beneficial effects on post-implant valve hemodynamics and perhaps long-term valve durability. AREAS COVERED: This is an expanded overview of BVF and BVR to facilitate VIV transcatheter aortic valve replacement (TAVR), with detailed discussion on lessons learned from bench testing studies and translation to procedural technique and clinical experience incorporating up-to-date evidence and experience with BVF in non-aortic positions. EXPERT OPINION: BVF and BVR improve valve hemodynamics following VIV-TAVR, with timing of BVF being an important determinant of procedure safety and efficacy; however, longer-term data are needed to determine long-term clinical outcomes including mortality, valve hemodynamics, and valve reintervention. In addition, further research will be needed to understand the safety and efficacy of these procedures in any new generation BSV or THV and to better define the role of these techniques in the pulmonic, mitral, and tricuspid positions.