Bioprosthetic Valve Fracture During Valve-in-Valve TAVR in a Degenerated Surgical Aortic Valve.

backgroundValve-in-valve transcatheter aortic valve replacement (ViV-TAVR) in degenerated surgical bioprostheses, including less characterized valves such as those manufactured by Braile Biomédica, may be limited by constrained expansion and high residual gradients, particularly in small surgical valves. CASE SUMMARY: An 89-year-old man presented with acute heart failure due to degeneration of a 23-mm Braile surgical aortic bioprosthesis with inherently small true internal diameter. ViV-TAVR with a 23-mm self-expanding valve resulted in a high residual gradient despite appropriate positioning. Given the absence of alternative therapeutic options, intentional high-pressure postdilatation using a noncompliant balloon was performed. This achieved bioprosthetic valve fracture (BVF), confirmed by fluoroscopy and computed tomography, leading to optimal transcatheter valve expansion, marked gradient reduction, and clinical improvement. DISCUSSION: This case provides imaging-confirmed evidence of BVF in a degenerated Braile valve performed in the clinical setting, establishing the structural behavior of this specific prosthesis in human anatomy. TAKE-HOME MESSAGES: Small surgical bioprostheses with limited or poorly characterized true internal diameter are at high risk for severe residual gradients after ViV-TAVR. BVF, guided by multimodality imaging, can be a decisive strategy to optimize transcatheter valve expansion and hemodynamics.