High-pressure Post-dilation following Transcatheter Valve-in-Valve Implantation in Small Surgical Valves.

Aims: Residual gradients >20 mmHg after transcatheter valve-in-valve (ViV) implantation are associated with worse survival. This study aimed to evaluate the feasibility of high-pressure post-dilation with a noncompliant balloon after transcatheter ViV implantation in small surgical valves to optimise haemodynamics. Methods and results: Thirty patients underwent ViV implantation in surgical valves with internal dimension <= 19 mm. High-pressure post-dilation to 16-20 atmospheres with a non-compliant balloon was performed in 12 patients and 18 patients underwent ViV without post-dilation. SAPIEN 3 and Evolut valves were used in 10 and two patients, respectively. The mean aortic valve (AV) gradient decreased by 11.3 mmHg following high-pressure post-dilation (18.7 +/- 7.9 mmHg immediately post ViV to 7.5 +/- 2.6 mmHg following high-pressure post-dilation, p<0.01). There were no cases of aortic mot rupture. High-pressure post-dilation, compared to no post-dilation, was associated with lower invasive AV mean gradients at the end of the ViV procedure (8.2 +/- 3.5 mmHg vs. 17.3 +/- 7.9 mmHg, p=0.001) as well as lower day 1 (18.0 +/- 4.5 mmHg vs. 25.0 +/- 8.1 mmHg, p=0.016) and 30-day gradients (19.8 +/- 2.5 vs. 26.5 +/- 11.0, - 0.038) on transthoracic echocardiography. Conclusions: High-pressure post-dilation of small surgical valves following transcatheter ViV implantation results in a significant improvement in post-procedure haemodynamics.