Balloon aortic valvuloplasty to bridge and triage patients in the era of trans-catheter aortic valve implantation.

OBJECTIVES: To describe the use of balloon aortic valvuloplasty (BAV) as a method of selecting patients for definitive aortic valve therapy.

BACKGROUND: BAV is a temporising treatment for aortic stenosis, previously used for palliation or bridge to surgery. The advent of transcatheter aortic valve implantation (TAVI) has developed a new indication for BAV-as a therapeutic trial.

METHODS: This is a descriptive series of 33 consecutive patients treated between 2008 and 2010. Standard BAV retrograde technique was used. Hemodynamic results and survival were recorded; destination valve therapy was offered based on clinical response. The reasons for nonresponse were explored.

RESULTS: Procedural success was achieved in all patients, valve area improved 0.36 ± 0.14 cm(2) , mean gradient by 20 ± 9.5 mm Hg and peak catheter gradient by 28.2 ± 17 mm Hg. Thirty-day mortality was 3% and 6-month mortality 15%. Twelve patients had no clinical improvement and were managed conservatively; two others demonstrated temporary occlusion of the left main by native leaflets during BAV. The remaining 19 patients improved and were offered valve therapy (10 TAVI and five aortic valve replacement). Post hoc analysis of the groups found higher prevalence of left ventricular impairment (90% vs. 29%, P = 0.001) and higher maintenance diuretic dose (Furosemide equivalent) 111.1 mg vs. 39.1 mg, P = 0.003) in the non-responders.

CONCLUSION: BAV may be used to assess whether a patient might improve from definitive aortic valve treatment, particularly in those patients with left ventricular dysfunction or chronic obstructive pulmonary disease (COPD) where assessment is inconclusive or there remain concern about symptom reversibility. BAV can also be used to screen for the possibility of left main occlusion by native leaflets during TAVI.