Balloon Aortic Valvuloplasty in the Era of TAVI
Background The use of balloon aortic valvuloplasty (BAV) has resurged since the development of transcatheter aortic valve replacement (TAVR). The aim of our study was to determine the procedural and long-term outcomes of patients treated by BAV in the early TAVR era.
Methods From 2005 to 2008, 323 consecutive patients presenting with severe aortic stenosis were treated by BAV in our institution.
Results Mean age and logistic EuroSCORE were 80.5 ± 9.9 years and 28.7% ± 12.5%, respectively. The effective orifice area increased from 0.68 ± 0.25 to 1.12 ± 0.39 cm (P < .001) after BAV. Inhospital major complications occurred in 22 patients (6.8%), with a mortality rate of 2.5%. Eighty-five patients (26.3%) were bridged to surgical aortic valve replacement (SAVR, 9.6%) or TAVR (16.7%). Twenty-eight patients (8.7%) had at least 1 repeat BAV. Two hundred ten patients (65%) received only medical therapy post-BAV. Mean duration of follow-up was 20.7 ± 20.0 months. Kaplan-Meier analysis demonstrated that survival after single BAV was poor. Patients treated by BAV followed by SAVR or TAVR had the highest long-term survival rate (P < .001). Multivariable analysis revealed that logistic EuroSCORE, severe aortic regurgitation and stroke complications post-BAV, and medical therapy post-BAV were independent predictors of mortality.
Conclusions The results of our study suggest that BAV is an acceptable bridge to SAVR or TAVR in a very high-risk population not immediately suitable for definitive therapy. Balloon aortic valvuloplasty remains only a brief temporizing procedure with a poor long-term outcome without subsequent definitive therapy.
Balloon aortic valvuloplasty (BAV) was introduced by our group in 1985 and was initially proposed as an alternative to surgical aortic valve replacement (SAVR) in elderly and/or high-risk patient with aortic stenosis (AS). Initial enthusiasm in the late 1980s for BAV was subsequently tempered by studies demonstrating high rates of complications, lack of durability, and little or no impact on long-term survival. Until recently, the use of BAV had significantly waned, restricted to very high-risk patients with severe heart failure or cardiogenic shock, often as a bridge to SAVR.
Because of technical improvements with reduction of sheath diameter; rapid pacing and vascular closure devices; and, most importantly, the introduction of transcatheter aortic valve replacement (TAVR) in 2002, there has been a resurgence in the use of BAV. In our institution, with an extensive experience of BAV and a high volume of TAVR, patients with AS and congestive heart failure, severely depressed left ventricular ejection fraction (LVEF), or cardiogenic shock, who may be eligible for definitive therapy (TAVR or SAVR), often undergo BAV. Other indications include symptomatic patients before urgent noncardiac surgery and less frequently as a compassionate procedure to relieve symptoms.
A recent series of patients undergoing BAV between 2000 and 2009 concluded that complication rates and procedural success have improved and that BAV is an acceptable bridge to TAVR and SAVR. However, the proportion of patients treated by BAV as a bridge to TAVR was low in this study (5% of the overall population). The aim of our study was, therefore, to determine the procedural success, complication rates, and long-term survival of a large cohort of very high-risk patients with AS undergoing BAV as a potential bridge to definitive therapy.
Abstract and Introduction
Abstract
Background The use of balloon aortic valvuloplasty (BAV) has resurged since the development of transcatheter aortic valve replacement (TAVR). The aim of our study was to determine the procedural and long-term outcomes of patients treated by BAV in the early TAVR era.
Methods From 2005 to 2008, 323 consecutive patients presenting with severe aortic stenosis were treated by BAV in our institution.
Results Mean age and logistic EuroSCORE were 80.5 ± 9.9 years and 28.7% ± 12.5%, respectively. The effective orifice area increased from 0.68 ± 0.25 to 1.12 ± 0.39 cm (P < .001) after BAV. Inhospital major complications occurred in 22 patients (6.8%), with a mortality rate of 2.5%. Eighty-five patients (26.3%) were bridged to surgical aortic valve replacement (SAVR, 9.6%) or TAVR (16.7%). Twenty-eight patients (8.7%) had at least 1 repeat BAV. Two hundred ten patients (65%) received only medical therapy post-BAV. Mean duration of follow-up was 20.7 ± 20.0 months. Kaplan-Meier analysis demonstrated that survival after single BAV was poor. Patients treated by BAV followed by SAVR or TAVR had the highest long-term survival rate (P < .001). Multivariable analysis revealed that logistic EuroSCORE, severe aortic regurgitation and stroke complications post-BAV, and medical therapy post-BAV were independent predictors of mortality.
Conclusions The results of our study suggest that BAV is an acceptable bridge to SAVR or TAVR in a very high-risk population not immediately suitable for definitive therapy. Balloon aortic valvuloplasty remains only a brief temporizing procedure with a poor long-term outcome without subsequent definitive therapy.
Introduction
Balloon aortic valvuloplasty (BAV) was introduced by our group in 1985 and was initially proposed as an alternative to surgical aortic valve replacement (SAVR) in elderly and/or high-risk patient with aortic stenosis (AS). Initial enthusiasm in the late 1980s for BAV was subsequently tempered by studies demonstrating high rates of complications, lack of durability, and little or no impact on long-term survival. Until recently, the use of BAV had significantly waned, restricted to very high-risk patients with severe heart failure or cardiogenic shock, often as a bridge to SAVR.
Because of technical improvements with reduction of sheath diameter; rapid pacing and vascular closure devices; and, most importantly, the introduction of transcatheter aortic valve replacement (TAVR) in 2002, there has been a resurgence in the use of BAV. In our institution, with an extensive experience of BAV and a high volume of TAVR, patients with AS and congestive heart failure, severely depressed left ventricular ejection fraction (LVEF), or cardiogenic shock, who may be eligible for definitive therapy (TAVR or SAVR), often undergo BAV. Other indications include symptomatic patients before urgent noncardiac surgery and less frequently as a compassionate procedure to relieve symptoms.
A recent series of patients undergoing BAV between 2000 and 2009 concluded that complication rates and procedural success have improved and that BAV is an acceptable bridge to TAVR and SAVR. However, the proportion of patients treated by BAV as a bridge to TAVR was low in this study (5% of the overall population). The aim of our study was, therefore, to determine the procedural success, complication rates, and long-term survival of a large cohort of very high-risk patients with AS undergoing BAV as a potential bridge to definitive therapy.
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