Simplified dual-indeflator approach for bioprosthetic valve fracture

A problem-solving step by step tutorial

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Summary

Bioprosthetic valve fracture (BVF) during valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is an important technique to optimize the haemodynamic outcomes of the new transcatheter valve¹. This method involves using a high-pressure balloon to fracture the rigid frame of a failing surgical bioprosthesis, thereby allowing an effective deployment and expansion of the new transcatheter valve².

This technique is particularly useful when the bioprosthetic valve has a small internal diameter (≤ 21 mm).

Although generally effective, the procedure carries risks such as prolonged rapid pacing, extended hypotension, ischemic stroke and potential damage to surrounding cardiac structures. Therefore, it requires a quick execution with an operator expertise and simplified procedural set-up¹.

The Problem

Standard BVF procedure necessitates several sequential maneuvers within a very short time frame, including:

1. Inflating the balloon with a 50 ml syringe while the 3-way stopcock connects the syringe and balloon
2. Simultaneously applying forward pressure on syringe and rotating the 3-way stopcock to connect the indeflator and balloon
3. Switching to pressure indeflator
4. Further inflating the balloon with an indeflator (push and then rotation) until achieving BVF
5. Balloon deflation. This multi-step process is demanding and increases required time, thereby introducing the potential for operator error and patient complications (prolonged rapid pacing and extended hypotension)

Principal idea

The principal idea was to simplify the procedural set-up, minimize operator maneuvers, and shorten the duration of rapid pacing. Overall, this could potentially reduce the risks of this procedure. Despite being previously reported in one review article², this technique has been largely underutilized, to the best of our knowledge.

Material needed

• 1 large volume indeflator – “primary indeflator” (example: Edwards / Atrion QL38®)
• 1 standard indeflator with pressure monitor – “secondary indeflator” (example: any PCI indeflator)
• 3-way stopcock
• 1 high-pressure balloon (Atlas Gold Bard® or True Bard®)
• Contrast-saline mixture (85/15 ratio)

Method step-by-step

Step 1

 Standard preparation and de-airing of the high-pressure balloon. Assembly of high-pressure balloon, 3-way stopcock, large volume indeflator and standard indeflator with pressure monitor.

Step 2

Introduction and positioning of the high-pressure balloon across the surgical bioprosthesis. Reassurance on the position of 3-way stopcock (open in all 3 directions), and de-aired fluid (contrast/saline mixture) filled indeflators.

Step 3 - Bioprosthesis valve fracture

• Step 3a: Manual balloon inflation by pushing the unlocked handle of the large volume “primary indeflator”.

• Step 3b: Manual balloon inflation by rotating the locked handle of the large volume “primary indeflator” and observation of pressure monitor on the standard “secondary indeflator”.
  Tip: It is advised that the 3^rd operator or a nurse/technician loudly states pressure on the indeflator as it increases.

• Step 3c:  Following the BVF (visual and/or pressure confirmation): Manual balloon deflation by pulling the unlocked handle of the large volume “primary indeflator”, followed by handle locking.

Points of specific attention

• De-air the system thoroughly.
• The "primary indeflator" should be completely filled with fluid.
• The "secondary indeflator" with pressure monitor should be partially filled with fluid to allow better pressure conduction, and to leave option of applying additional negative pressure if needed post fracture. Avoid complete fluid filling of "secondary indeflator".
• The "secondary indeflator" should be positioned to be clearly visible.
• It is advised that the one operator or a nurse/technician loudly states pressure on the indeflator as it increases.
• Plan the procedure and know the approximate fracture pressure for specific surgical valve.

A word from the reviewer - Alexander Wolf

References:

1. Hashimoto G, et al. New Insights and Perspective on Bioprosthetic Valve Fracture From Bench Testing and Computed Tomography Analysis. Struct Heart. 2024;8(3):100276. doi: 10.1016/j.shj.2023.100276.
2. Sreedharan et al. Bioprosthetic Valve Fracture to Facilitate Valve-in-Valve Transcatheter Aortic Valve Replacement. Structural Heart. 2021;5(1):24-30. doi: 10.1080/24748706.2020.1844354.