Outcome of bioprosthetic valve fracture in small-valve ViV-TAVI procedures

Background Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in degenerated surgical bioprostheses may achieve suboptimal hemodynamic results, particularly in patients with small surgical valves (valve size23 mm, stent inner diameter 21 mm). These patients are at increased risk of residual patient–prosthesis mismatch and elevated transvalvular pressure gradients. Bioprosthetic valve fracture (BVF) may facilitate optimal valve expansion and improve hemodynamic performance after ViV-TAVI. We compared clinical and hemodynamic outcomes of ViV-TAVI with and without adjunctive BVF in patients with small surgical aortic bioprostheses. Methods We retrospectively analyzed ViV-TAVI procedures from our institutional TAVI registry. Adjunctive BVF was performed when considered feasible in patients with significant residual gradients following ViV-TAVI. Echocardiography was performed at baseline and prior to hospital discharge. Outcomes were compared between patients with small surgical aortic bioprostheses treated with and without BVF. Optimal hemodynamic outcome was defined as a final echocardiographic mean transvalvular gradient 20 mmHg. Results Between 2010 and 2025, 1,469 TAVI procedures were performed at our institute, including 44 ViV-TAVI cases. Of these, 37 patients had small surgical aortic bioprostheses. BVF was performed in 13 patients (35%) with small surgical bioprostheses, while the others underwent standard ViV-TAVI alone. At discharge, patients undergoing adjunctive BVF achieved lower final echocardiographic mean transvalvular gradients compared with those treated without BVF (15.9±4.9 vs. 20.0±9.3 mmHg) (Figure 1). A final mean transvalvular gradient 20 mmHg was achieved in 11 of 13 patients (84.6%) in the BVF group, compared with 13 of 24 patients (54.2%) treated with standard ViV-TAVI alone. No BVF-related procedural complications were observed. Conclusions In patients with small surgical aortic bioprostheses undergoing ViV-TAVI, adjunctive BVF was safe and associated with significantly improved valve hemodynamics compared with standard ViV-TAVI alone.These findings support BVF as an effective targeted adjunctive strategy when surgical valve size limits optimal ViV-TAVI outcomes.