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Schematic diagrams of the various types of aortic valve stenosis. (A) Normal tri-leaflet aortic valve, (B) congenital aortic stenosis–bicuspid type, (C) rheumatic aortic stenosis–commissural fusion leading to a central orifice, and (D) calcific aortic stenosis with nodule formation.
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Aortic balloon valvuloplasty (BAV) was initially devised in the 1980s as an alternative procedure to the surgical treatment of aortic stenosis, with the theory behind it being both minimally invasive as well as having a lower complication rate [Hara H, et al. Percutaneous balloon aortic valvuloplasty revisited: time for a renaissance? Circulation 2...
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Citations
... Aortic stenosis (AS) begins with a long asymptomatic period [3]. Once symptomatic, survival becomes poor unless the outflow obstruction is relieved [4][5][6]. Retrospective studies have shown that if the patient experiences symptoms of angina the medial survival is 5 years, syncope 3 years, and heart failure 2 years [4,7,8]. Surgical and Transcatheter aortic valve replacement (TAVR) have been shown to improve symptoms and overall survival in patients with severe, symptomatic AS [9,10]. ...
... This approach is, nevertheless, based purely on expert opinions and was not tested in any randomised, controlled trials. The rationale behind the pre-dilatation comes from the experience with palliative balloon valvuloplasty used in selected cases as a symptom relief therapy or bridge-to-surgery strategy [12,13]. While the immediate haemodynamic effects confirmed by echocardiographic imaging remain favourable, the procedure itself carries multiple limitations including high restenosis rate, risk of peri-procedural complications, and limited survival benefit [14,15]. ...
Transaortic valve implantation (TAVI) has a well-established position in the treatment of high-risk and inoperable patients with severe aortic stenosis (AS). The TAVI protocol requires a pre-dilatation for native valve preparation.
To assess the safety and feasibility of TAVI without pre-dilatation and to compare it with the procedure with pre-dilatation.
Out of 101 TAVI patients, in 10 the procedure was performed without balloon predilatation, and 8 patients were included in the analysis. The procedural, echocardiographic, and clinical outcomes were compared with a case control matched cohort (1: 2 ratio). A 12-month follow-up was done in all cases.
The procedure was successfully completed in all patients in the study group (SG), but there was one procedural failure in the control group (CG). All patients received a CoreValve (Medtronic) bioprosthesis. There was a significant immediate decrease in transvalvular gradients (TG) in both study arms after the procedure (SG: mean TG: from 46.0 ±14.0 mm Hg to 10.0 ±4.8 mm Hg, p < 0.001; CG: mean TG: from 55.9 ±12.0 mm Hg to 9.9 ±2.9 mm Hg, p < 0.001). A marked increase in the effective orifice areas was observed in both cohorts (SG: 1.63 ±0.13 cm(2) and CG: 1.67 ±0.25 cm(2), p = 0.75). The periprocedural complication rate was equally distributed in both arms. The 12-month all-cause mortality was 12.5% in both groups.
The direct TAVI approach seams to be safe and feasible. The clinical and echocardiographic results are not different from those achieved in patients treated with standard TAVI protocol with pre-dilatation.
Purpose
In elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.
Methods
We conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.
Results
Among the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).
Conclusions
preoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.
Background
Balloon aortic valvuloplasty (BAV) has seen renewed interest since the advent of transcatheter aortic valve implantation (TAVI). The study aimed to characterise a contemporary BAV cohort and determinants of clinical outcomes.
Methods
Patients undergoing BAV at a single tertiary centre were retrospectively reviewed over a 10-year period, and functional and mortality outcomes were reported with up to a 2-year follow-up.
Results
224 patients (aged 82.5±8.3 years; 48% female) underwent BAV over the study period. Indications were either destination treatment (39%) or bridge-to-valve replacement (61%)—including bridge-to-decision (29%), symptom relief while on the waitlist (27%), and temporary contraindications to TAVI/aortic valve replacement (AVR) (5%). The mean reduction of aortic mean pressure gradient was 38%. Procedural mortality occurred in 0.5%, stroke in 1.3%, and major bleeding in 0.9%. Twelve-month mortality was 36% overall, and 26% and 50% in the bridging and destination groups, respectively. New York HeartAssociation (NYHA) class improved by ≥1 at 30 days in 50%. Among the bridge-to-TAVI/AVR group, 40% proceeded to TAVI/AVR within 12 months following BAV. In multivariate analysis, active malignancy at baseline (OR: 4.4, 95% CI: 1.3 to 15.1, p=0.02), smoking history (OR: 3.3, 95% CI: 1.3 to 7.9, p<0.01), LVEF ≤30% at baseline (OR: 3.2, 95% CI: 1.3 to 7.6, p<0.01), destination treatment (OR: 2.2, 95% CI: 1.0 to 4.9, p=0.04) were all associated with 12-month mortality.
Conclusions
BAV remains a useful procedure with relatively low rates of complications, however, 1-year mortality rates are high. Contemporary indications for BAV include a bridge to definitive valve replacement or destination treatment.
The last several decades have witnessed a huge expansion of surgical and interventional treatment of cardiac disease. Axel Cappelen from Oslo, Norway was one of the first to operate on the heart, something that had until then, been considered foolish and without chance of success.1 Cappelen dared to operate on the heart in spite of Billroth's stark warning against such "unwise" attempts as he ligated a bleeding coronary artery caused by a stabbing injury. Most of the innovation in recent years has been within the interventional cardiology domain in contrast to the first 7 decades of the 20th century, when surgeons dominated. Cardiac surgeons have developed less invasive procedures, although the most common surgical incision is based on the time-honoured and large median sternotomy incision. Many surgeons continue to prefer the concept of "Grosse Chirurgen, Grosse Schnitte" and have stayed away from minimisation and continue to use direct vision, usually augmented by magnification glasses, median sternotomy and cardiopulmonary bypass (CPB). However, new technology has made the need for CPB less important2 . In this article a selection of recently developed devices for cardiac intervention will be described.
Background: To demonstrate the safety and efficacy of the Leaflex™ during surgical aortic valve replacement and examination of excised valve tissue. In a growing elderly population with multiple comorbidities, increasing frailty and often limited mobility a simple mechanical intervention for severe aortic stenosis (AS) may be appropriate in selected patients as a standalone first intervention. The Leaflex™ is a novel percutaneous device for restoring calcified aortic valve leaflet mobility by mechanical scoring.
Methods: Five patients with severe AS (including one with fused leaflets) were treated with the Leaflex™ during cardiopulmonary bypass prior to valve excision. Estimated pressure gradient (PG) was assessed by the force required to pull a cone through the valve before and after Leaflex therapy. The change in estimated aortic valve area (AVA) was then calculated based on the Gorlin equation. The excised aortic leaflets were examined histologically, radiographically and by micro-CT, for leaflet integrity.
Results: The Estimated PG based on the pullback force decreased by 75% (±2.7%) and estimated AVA increased by 99% (±11%) across 4 tri-leaflet aortic valves and by 53% and 46% respectively in one valve with fused commissures. Micro-CT and histology confirmed ventricular surface integrity at the site of scoring in all 5 cases.
Conclusions: In the intraoperative setting, the Leaflex™ was effective in decreasing estimated PG and increasing estimated AVA with maintenance of valve tissue integrity. Although the results of the pressure gradient are estimates, these encouraging results support further assessment of the Leaflex™ approach in patients with calcific AS.
Severe aortic valve stenosis is a frequent valvular disease and a common cause of morbidity and mortality especially in the elderly. Definitive treatment is traditionally represented by surgical aortic valve replacement in patients with an acceptable surgical risk. In the last years, transcatheter aortic valve implantation (TAVI) has been established as a valid alternative to surgery in high- or intermediate-risk patients, and nowadays it is also recommended by international guidelines. Balloon aortic valvuloplasty was initially introduced in the 1980s as a minimally invasive procedure for the treatment of severe aortic stenosis, but it soon proved limited by a high complication rate and incidence of restenosis at short- or midterm. However, the successes of TAVI have brought new support to balloon aortic valvuloplasty, such that this procedure now rests as a suitable alternative for temporary palliation and symptomatic relief in patients who cannot undergo surgical aortic valve replacement because of prohibitive comorbidities or other high-risk features while enabling more refined individualized decision-making for subjects with borderline indications to TAVI. Indeed, in the last years, there have been significant technical advances in devices (e.g., balloons and guidewires) and techniques (e.g., the introduction of vascular closure devices and newer imaging modalities) for balloon aortic valvuloplasty, further supporting its contemporary clinical role. Moreover, balloon aortic valvuloplasty also plays a key role as a bridge to therapy to either surgical or transcatheter aortic valve replacement in a subgroup of patients with aortic stenosis requiring temporary hemodynamic stabilization. Finally, it also represents an important step in many TAVI procedures, as either predilation before device placement or as postdilation to manage valve underexpansion.
A 91-year-old woman was admitted to our hospital for treatment of congestive heart failure with severe aortic stenosis. After admission, she developed a high fever due to pneumonia and worsened heart failure. We could not perform transcatheter aortic valve implantation (TAVI) because of active infection; therefore, retrograde balloon aortic valvuloplasty (BAV) was urgently performed. A complete atrioventricular block and severe functional mitral regurgitation appeared suddenly after BAV in the absence of mechanical disorders. Her condition improved after several days in our intensive care unit. Pacemaker implantation and TAVI were then performed, and the patient was discharged from our hospital. MR could sometimes exacerbate after BAV in clinical practice; therefore, we set out to report this case.
