Role of Balloon Aortic Valvuloplasty in the Transcatheter Aortic Valve Implantation Era

Abstract

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.