Balloon Fracturing Valve-in-Valve: How to Do It and a Case Report of TAVR in a Rapid Deployment Prosthesis

Figures

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  Figure 1. Example of some information obtained in the ViV Aortic App. In this simulation, the true ID for a Magna Ease 21 mm bioprosthesis is 19 mm, and a TAVR using an Evolut R 23 mm self-expanding or a Sapien 3 20/23 mm balloon-expandable would be recommended.

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  Figure 2. Example of a balloon valve frame fracture using a noncompliant balloon and high-pressure inflation. Observe the prosthesis waist before (first image) and after (second image) the balloon inflation.

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  Figure 3. Maximum recommended balloon size for self-expanding CoreValve/Evolut valves (adapted from Chhatriwalla [18]).

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  Figure 4. Chart of Inovare® Alpha sizes.

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  Figure 5. As Inovare® Alpha is not present in the ViV App, we looked at the Perceval valve, which has a similar true ID. In a true ID of 17.5–19 mm, an Evolut R 23 mm is suggested.

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  Figure 6. ViV App suggestion of depth of implantation of an Evolut R 23 mm in a Perceval valve.

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  Figure 7. Step-by-step procedure. (a) Predilatation and valve cracking using an Atlas 20 mm noncompliant balloon while injecting contrast in the ascending aorta to simultaneously evaluate the left coronary artery flow. (b) Immediate prosthesis cracking and expansion with mean gradient reduction and PVL resolution. (c) Slow Evolut R 23 deployment immediately below the previously implanted rapid deployment valve. (d) Aortic regurgitation reduction on TEE and expansion of the previously implanted rapid deployment valve. (e) Final aortogram showing no aortic regurgitation and both prostheses proper expansion with a mean gradient of 8 mmHg.