Increase In Aortic Valve Area Research Articles

Three-year outcome after balloon aortic valvuloplasty. Insights into prognosis of valvular aortic stenosis.

To identify predictors of long-term outcome after balloon aortic valvuloplasty, we analyzed data on 674 adults (mean age, 78 +/- 9 years; 56% were women) undergoing this procedure at 24 clinical centers who had a mean initial increase in aortic valve area of 0.3 cm2. Baseline data included clinical, echocardiographic, and catheterization variables. Follow-up data included mortality, cause of death, rehospitalization, 6-month echocardiography, and functional status. Kaplan-Meier curves and log-rank tests were used to evaluate survival in subgroups. Multivariate Cox regression models were used to identify independent predictors of survival. Overall survival was 55% at 1 year, 35% at 2 years, and 23% at 3 years, with the majority of deaths (70%) classified as cardiac by an independent review committee. Rehospitalization was common (64%), although 61% of survivors at 2 years reported improved symptoms. Echocardiography at 6 months (n = 115) showed restenosis from the postprocedural valve area of 0.78 +/- 0.31 cm2 to 0.65 +/- 0.25 cm2 (P < .0001). With stepwise multivariate analysis, sequentially adding clinical, echocardiographic, and catheterization variables, the overall model identified independent predictors of survival as baseline functional status, baseline cardiac output, renal function, cachexia, female gender, left ventricular systolic function, and mitral regurgitation. Baseline and postprocedural variables were examined to identify which subgroup of patients has the best outcome after aortic valvuloplasty. A "lower-risk" subgroup (28% of the study population), defined by normal left ventricular systolic function and mild clinical functional limitation, had a 3-year survival of 36% compared with 17% in the remainder of the study group. Long-term survival after balloon aortic valvuloplasty is poor with 1- and 3-year survival rates of 55% and 23%, respectively. Although survivors report fewer symptoms, early restenosis and recurrent hospitalization are common.

Contribution of mitral valve reserve capacity to sustained symptomatic improvement after balloon valvutomy in mitral stenosis: Implications for restenosis for restenosis

Objectives. To explain the discrepancy between the symptomatic status of patients and the hemodynamically calculated mitral valve area during long-term follow-up after mitral balloon valvulotomy, mitral valve orifice variability alter dobutamine infusion was investigated in two groups of patients.Background. A significant increase in aortic valve area with increased aortic transvalvular flow has been reported in patients with calcific aortic stenosis after aortic balloon valvulotemy. A similar phenomenon with regard to the mitral valve has not been studied in detail.Methods. Group 1 comprised 10 patients (mean age 33 ± 9 years) with untreated mitral stenosis. Group 2 comprised 29 consecutive patients (mean age 32 ± 7 years) who underwent successful percutaneous mitral balloon valvulotomy 13 ± 2 months before the study.Results. After dobutamine infusion, heart rate and cardiac index increased significantly in both groups. The mean pulmonary artery pressure, mitral valve gradient and pulmonary capillary pressure remained unchanged in Group 2 but increased significantly in Group 1. The mean mitral valve area was significantly larger in Group 2 after dobutamine infusion that at baseline (1.9 ± 0.5 vs. 2.4 ± 0.6 cm2, p < 0.0001) but was unchanged in Group 1 (1.2 ± 0.2 vs. 1.3 ± 0.3 cm2, p = NS). The mean mitral valve area in seven patients in Group 2 (24%) was ≤1.5 cm2before dobutamine infusion (1.3 ± 0.4 cm2), which was defined as restenosis. In five of these seven patients who had minimal or no symptoms, the mitral valve area increased significantly after dobutamine infusion (1.3 ± 0.1 vs. 1.9 ± 0.1 cm2). in the other two patients who were symptomatic, the mitral valve area did not change after dobutamine infusion. These two patients were iden- tified as having “tree” restenosis, and reduction of the mitral valve was performed in both.Conclusions. In patients who underwent mitral balloon valvulotomy, increased mitral valve reserve capacity contributed to symptomatic improvement on long-term follow-up. Dobutamine infusion may be helpful in detecting clinically significant restenosis.

Ejection load changes in aortic stenosis. Observations made after balloon aortic valvuloplasty.

To investigate complementarity and competitiveness between the intrinsic and extrinsic components of the total left ventricular systolic load, hemodynamic data from 18 elderly subjects with severe aortic stenosis were analyzed before and after balloon dilation of the stenosed aortic valve. Multisensor micromanometric pressure measurements allowed calculation (simplified Bernoulli equation) of the ejection velocity and aortic input impedance spectra. Despite a 32% increase in the aortic valve area (from 0.56 +/- 0.04 to 0.74 +/- 0.05 cm2 [mean +/- SEM], p < 0.01), the peak left ventricular systolic pressure fell by only 12% (from 189 +/- 10 to 167 +/- 8 mm Hg, p < 0.01). This was accompanied by an increase in the impedance at the same cardiac output. In a subset of patients (n = 9) in whom the peak aortic systolic pressure rose after valvuloplasty (from 115 +/- 10 to 128 +/- 12 mm Hg, p < 0.01), a 40% increase in the aortic valve area was accompanied by a marked increase in the aortic input impedance. In this subset, the steady component of the aortic input impedance increased by 24% (from 960 +/- 96 to 1,188 +/- 134 dyne.sec/ml, p < 0.05), and the characteristic impedance increased by 25% (from 106 +/- 13 to 132 +/- 19 dyne.sec/ml, p < 0.05). Because of an increased aortic impedance acutely following the procedure, the total left ventricular systolic load after balloon dilation of the stenotic valve was only slightly decreased despite a significant increase in aortic valve area. This represents an example of complementarity and competitiveness between the intrinsic and extrinsic components of the total systolic ventricular load. It may explain why improvement in left ventricular performance may be modest acutely following balloon aortic valvuloplasty.

Beat-by-beat aortic valve area measurements indicate constant orifice area in aortic stenosis: analysis of Doppler data with varying RR intervals.

Gorlin formula calculation of aortic valve area suggests that orifice area increases in patients with aortic stenosis with rising cardiac output. Evidence that aortic orifice area varies was sought in patients with aortic stenosis by analyzing Doppler data beat by beat versus RR interval in 22 patients with spontaneous RR variability. Stroke volume increased in all patients from minimum to maximum RR interval by 129% +/- 19%. Over the same range of RR intervals, assessment of aortic valve area by (A) simultaneous inner and outer continuous wave Doppler signals, or (B) nonsimultaneous RR-matched pulsed wave Doppler from the left ventricular outflow tract and continuous wave Doppler from the aortic valve failed to suggest an increase in aortic valve area. A positive relationship between aortic valve area and RR interval was not consistently observed with the exception of seven out of eight patients with mild to moderate (pulsed wave Doppler/continuous wave Doppler time velocity integral ratio of 0.3 to 0.7) aortic stenosis (p less than 0.05). Beat-by-beat measurements of aortic valve orifice area using Doppler techniques do not suggest that the aortic stenosis orifice varies over a wide range of RR intervals and stroke volumes.

Predictors of Event-Free Survival after Balloon Aortic Valvuloplasty

Balloon aortic valvuloplasty was developed as an alternative to aortic-valve replacement in selected elderly patients with aortic stenosis. The use of this procedure is limited, however, by a high incidence of restenosis. Between December 1985 and April 1989, valvuloplasty was performed in 205 patients. We evaluated 40 demographic and hemodynamic variables as univariate predictors of event-free survival by Cox regression analysis and identified independent predictors of event-free survival by stepwise multivariate analysis. Early hemodynamic results indicated a decrease in the peak transaortic-valve pressure gradient from 67 +/- 28 to 33 +/- 15 mm Hg after valvuloplasty and an increase in aortic-valve area from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2 (P less than 0.001 for both comparisons). The rate of event-free survival (defined as survival without recurrent symptoms, repeated valvuloplasty, or aortic-valve replacement) was 18 percent over the mean (+/- SD) follow-up period of 24 +/- 12 months (range, 1 to 47). Significant predictors of event-free survival included the left ventricular ejection fraction and the left ventricular and aortic systolic pressure before valvuloplasty, and the percent reduction in the aortic-valve pressure gradient; the pulmonary-capillary wedge pressure was inversely associated with event-free survival. Although the predicted event-free survival rate for the entire patient group was 50 percent at one year (95 percent confidence interval, 43 to 57 percent) and 25 percent at two years (95 percent confidence interval, 19 to 31 percent), the probability of event-free survival at one year varied between 23 and 65 percent when patients were stratified according to three independent predictors: the aortic systolic pressure, the pulmonary-capillary wedge pressure, and the percent reduction in the peak aortic-valve gradient. The most important predictors of event-free survival after balloon aortic valvuloplasty were related to base-line left ventricular performance. The best long-term results after valvuloplasty were observed among patients who would also have been expected to have excellent long-term results after aortic-valve replacement.

Serial left ventricular performance evaluated by cardiac catheterization before, immediately after and at 6 months after balloon aortic valvuloplasty

Although impaired ventricular function has been shown to improve after aortic valve replacement, there are few data on hemodynamic changes after balloon aortic valvuloplasty based on follow-up catheterization. Of 71 patients surviving 6 months after balloon aortic valvuloplasty, 41 agreed to late recatheterization. All patients had pre- and postvalvuloplasty and 6 month catheterization data measured with high fidelity micromanometer pressure recordings and simultaneous digital subtraction left ventriculography.The hemodynamic result immediately after valvuloplasty included a reduction in the aortic valve gradient and a moderate increase in aortic valve area (0.51 ± 0.14 to 0.81 ± 0.19 cm2, p < 0.0001). Ejection fraction increased slightly (52 ± 18 to 55 ± 17%, p < 0.0001) despite a decrease in peak positive rate of rise of left ventricular pressure (dP/dt 1,650 ± 460 to 1,500 ± 490 mm Hg/s, p < 0.05). There was also a decrease in left ventricular afterload and a small decrease in preload.At 6 month recatheterization, the mean aortic valve gradient and area were similar to baseline values, with 31 (76%) of 41 patients demonstrating valvular restenosis. At 6 months many left ventricular hemodynamic variables, including peak positive dP/dt and stroke work, also resembled prevalvuloplasty values. However, left ventricular end-diastolic volume was reduced (111 ± 40 ml at 6 months versus 136 ± 52 ml before valvuloplasty, p < 0.01). The mean left ventricular ejection fraction was unchanged from prevalvuloplasty values in the study group of 41 patients, but was significantly improved in 9 of 15 patients with a baseline ejection fraction <50%.Thus, recatheterization at 6 months demonstrates left ventricular remodeling and a modest improvement in ventricular performance, with the left ventricle being less dilated while maintaining stroke work and cardiac output. These changes occur despite a high incidence of valve restenosis, indicating that balloon aortic valvuloplasty should be reserved for patients unable to tolerate surgical valve replacement.

Short-lasting hemodynamic and clinical benefits from percutaneous balloon valvuloplasty for calcific aortic stenosis.

In order to evaluate the short- and mid-term results of percutaneous aortic balloon valvuloplasty, 40 consecutive elderly patients, who had undergone balloon valvuloplasty for calcific aortic stenosis, were prospectively followed up by means of clinical and echo-Doppler examinations. Although valvuloplasty often dramatically improves hemodynamics and relieves symptoms, these benefits seem to be short-lived in most cases. Restenosis, defined as a loss of 50% or more of the increase in aortic valve area obtained by the dilatation, has a very high rate of occurrence. Aortic balloon valvuloplasty should therefore be reserved for truly inoperable cases and can be performed in hemodynamically unstable patients, who may later undergo surgery.

Complete Heart Block Developing during Aortic Valvuloplasty

We report the occurrence of CHB consequent to ABV in an 80-year-old white woman with calcific aortic stenosis. The patient underwent ABV with a balloon 20 mm in diameter, resulting in only a modest increase in aortic valve area and a decrease in aortic valve gradient. The procedure was complicated by transient intermittent CHB which required temporary transvenous pacemaking and resolved within 72 hours. A second ABV was performed four weeks later with a balloon 23 mm in diameter. This was complicated by persistent CHB which required placement of a dual-chamber pacemaker.

Early and late results of balloon valvuloplasty for severe aortic stenosis.

Balloon aortic valvuloplasty has been used as treatment for selected patients with severe aortic stenosis. We report our experience of 11 procedures, performed on ten patients between October 1987 and June 1988. The peak aortic systolic gradient was reduced by 53% from 77 +/- 22 to 37 +/- 14 mmHg (p less than 0.0001) whilst cardiac output did not change significantly (4.1 +/- 1.7 to 3.8 +/- 1.6 (p less than 0.0001) whilst cardiac output did not change significantly (4.1 +/- 1.7 to 3.8 +/- 1.6 L/min). Aortic valve area was increased by 50%, from 0.4 +/- 0.2 to 0.6 +/- 0.2 cm2 (p less than 0.0001). Initial symptomatic improvement was achieved in eight patients. Echocardiographically demonstrated aortic regurgitation did not increase after valvuloplasty. There were no deaths during the procedure, no embolic events and no femoral artery complications. The mean follow-up for survivors was 9 +/- 3 months. Five patients died and three had symptom recurrence at an average of 13 weeks (six-24 weeks). Only two patients reported a continued improvement in symptoms. Balloon aortic valvuloplasty produced a small increase in aortic valve area and a satisfactory initial clinical response, but there was a high incidence of symptom recurrence. The procedure may have a role in the short-term palliation of severely symptomatic patients who are unable to have aortic valve replacement.

Results of percutaneous valvuloplasty for calcific aortic stenosis with different balloon catheters

Percutaneous aortic valvuloplasty is a palliative treatment for patients with calcific aortic stenosis who would be poor candidates for surgical treatment. The results and associated complications of this procedure were analysed in a series of 47 patients in which different types of dilating catheters were used. In 25 patients a single balloon (19 mm) was used (group A), in 13 patients a bifoil balloon (2 x 15mm) (group B), and in the remaining nine patients (group C) a trefoil balloon (3 x 10mm) was used. An increase in aortic valve area was achieved in all patients. The results obtained with the bifoil balloon were better than with the other types of balloon catheter, with an increase in aortic area of + 118% vs. + 74% (monofoil) and + 76% (trefoil) (P less than 0.05). The tolerance of the inflation procedure was also better with this type of balloon, as it allowed for shorter inflation and deflation times. These results show that balloon aortic valvuloplasty, when indicated, is best performed with a bifoil balloon dilating catheter, and undue complications usually do not occur.

Analysis of the early rise in aortic transvalvular gradient after aortic valvuloplasty

The relationship between dynamic changes in aortic valve gradient and left ventricular ejection performance in the early period after successful percutaneous aortic valvuloplasty has not been described in detail. Accordingly 20 adult patients with severe symptomatic calcific aortic stenosis underwent first-pass radionuclide angiography and Doppler echocardiography before, immediately after, and 2 to 4 days after the valvuloplasty procedure. A significant ( p < 0.001) reduction in peak-to-peak (72 ± 24 mm Hg to 36 ± 11 mmHg) and mean (60 ± 20 mm Hg to 34 ± 9 mm Hg) transaortic gradient and an increase in aortic valve area (0.5 ± 0.2 cm 2 to 0.8 ± 0.2 cm 2) were measured by high-fidelity micromanometer catheters immediately after aortic valvuloplasty. Results of Doppler echocardiography showed a significant ( p < 0.001) immediate decrease in peak instantaneous (81 ± 22 mm Hg to 53 ± 15 mm Hg) and mean (48 ± 14 mm Hg to 31 ± 9 mm Hg) aortic gradients. However, 2 to 4 days later a significant ( p < 0.001) return of peak (56 ± 15 mm Hg to 65 ± 20 mm Hg) and mean (31 ± 9 mm Hg to 39 ± 12 mm Hg) transvalvular gradient occurred. Aortic valve area as determined by the continuity equation also increased from 0.4 ± 0.2 cm 2 to 0.6 ± 0.2 cm 2 immediately after the procedure ( p < 0.001), then partially returned to baseline (0.5 ± 0.2 cm 2; p < 0.005) at 2 to 4 days. Results of serial first-pass radionuclide angiography performed at the same time as the Doppler evaluations showed a continued decrement in left ventricular end-diastolic volume (184 ± 42 ml to 158 ± 35 ml to 151 ± 35 ml) and a trend toward an increase in stroke volume. Additionally the mean ejection fraction continued to improve during this period (42 ± 18% to 49 ± 19% to 52 ± 19%). These data indicate that the early rise in aortic valve gradient seen after percutaneous aortic valvuloplasty is likely due to both remodeling of the aortic valve architecture and a small increase in stroke volume.

Percutaneous Balloon Aortic Valvuloplasty: The State of the Art. A Review of Two Years Experience in Rouen

Since the first case performed by us in September 1985, percutaneous transluminal aortic valvuloplasty (PTAV) has been applied in Rouen in a broad clinical spectrum of patients with aortic stenosis. After our encouraging initial experience, there have been changes in our objectives and technique which have allowed us to proceed more quickly, with less discomfort to the patient, lower risk, and improved results. The development of a new device, a triple lumen‐double size balloon catheter has been a major advance as well as the use of extra‐stiff guidewires and arterial sheaths.Our series has grown to more than 300 patients, mostly elderly (mean age 73 ± 11, 25% at or above 80) and very ill (71% in NYHA functional class HI or IV). Indication for PTA V was either absolute contraindication to valve replacement (30%), increased surgical risk (31%), refusal of surgery (10%), or attempt to postpone surgery (29%).The largest balloon size used has been 20 mm or above (23 mm or even 25 mm) in 70% of the cases. The double‐balloon technique has been used in only 5% of the cases. In our series, PTAV resulted in a decrease in transvalvular peak gradient from 71 ± 26 mm Hg to 28 ± 13 mm Hg and an increase in aortic valve area from 0.54 ± 0.18 cm2 to 0.96 ± 0.33 cm2. With gained experience and the use of larger balloon sizes, the results have clearly improved: in the last 100 patients a valve area to or above 1 an2 has been obtained in 55% compared to 30% of the cases in our early experience. Patients less than 70 years old had the best results but the aortic stenosis was less severe before PTAV.The total procedural and post‐PTA V mortality was 4% and involved primarily very old patients. The nonfatal complication rate remained low. Clinical information for 204 patients followed for 12 ± 5 months has been obtained and repeat catheterization has been done in 56 patients at an average of 4.5 months after PTA V.The data confirms that PTA V is feasible and can be accomplished with a relatively low risk in an elderly and ill population and in patients with contraindication to valve replacement or very high surgical risk. The procedure alters the natural history of the disease in these patients, improving both symptoms and survival. Indications in other categories of patients deserve further studies.

Clinical and noninvasive hemodynamic results after aortic balloon valvuloplasty for aortic stenosis

Balloon valvuloplasty has been shown to be an effective treatment for adults with aortic stenosis, typically providing a 50 to 80% increase in aortic valve area and marked improvement in exertional dyspnea, angina and syncope. However, the duration of this hemodynamic and clinical improvement is uncertain. Forty-two patients were followed for 10.2 ± 0.5 months. Balloon valvuloplasty caused dramatic immediate reduction in the number of patients with moderate or severe dyspnea (80 to 14%), moderate or severe angina (39 to 2%) and syncope (30 to 2%). Furthermore, this improvement in symptoms continued for the duration of the follow-up period in most patients. Echocardiographic aortic valve mean gradient and area determined at 3-month intervals, however, showed a trend toward or return to prevalvuloplasty levels by 9 months' follow-up in 13 of 25 patients (52%), whereas 12 of 25 patients showed no deterioration in their hemodynamic parameters. This trend toward restenosis was accompanied by symptomatic deterioration in 5 of 13 patients (38%). This tendency toward restenosis in >50% of patients by 9 months underscores the need for further technical improvements if balloon valvuloplasty is to be widely applied. Even with these limitations, however, balloon valvuloplasty seems to provide a significant improvement in actuarial survival compared with the natural history of elderly patients with severe aortic stenosis.

Comparison of hemodynamic results of anterograde versus retrograde percutaneous balloon aortic valvuloplasty

Percutaneous balloon aortic valvuloplasty (PAV) has been reported in children and in selected adults with aortic stenosis using retrograde arterial catheterization. Some patients, however, cannot undergo retrograde catheterization because of atherosclerotic disease, previous vascular surgery or the presence of vessel tortuosity. Because PAV requires the use of large balloon dilating catheters, extreme bleeding and local arterial damage are potential complications. The results of PAV using the anterograde transseptal approach were compared with those using the retrograde arterial approach. Diminution in aortic gradient and increase in aortic valve area were similar in the 2 groups. Vascular complications were more common using the retrograde approach (4 vs 0). Thus, PAV can be performed successfully using anterograde transseptal catheterization. This technique of PAV could be particularly useful in patients who cannot undergo retrograde arterial catheterization.

Percutaneous balloon aortic valvuloplasty for aortic stenosis in elderly patients at high risk for surgery.

Six elderly patients had percutaneous balloon aortic valvuloplasty for severe, symptomatic calcific aortic stenosis because valve replacement surgery was considered too risky in five patients with severe coexisting cardiac or other medical problems and because one patient refused to have surgery. The procedure resulted in a significant reduction in the mean (+/-SD) aortic valve gradient, from 47 +/- 13 to 32 +/- 12 mm Hg (change, -32%, p less than 0.01), and a significant increase in the mean area of the aortic valve, from 0.64 +/- 0.12 to 0.90 +/- 0.17 cm2 (change, +40%, p less than 0.001). Blood loss from the femoral puncture site was the only major procedural complication. At a mean follow-up of 2 months after the procedure, all patients were alive and dyspnea had improved by two New York Heart Association functional classes in four patients and by one functional class in two patients. A significant short-term increase in aortic valve area and alleviation in symptoms can be achieved safely by percutaneous balloon aortic valvuloplasty in elderly patients with severe calcific aortic stenosis who are at high risk for surgical complications.

Rest and exercise hemodynamics in children before and after aortic valvotomy

The rest and exercise hemodynamics in children with congenital valvar aortic stenosis were studied before and after aortic valvotomy. Eighteen patients were studied at rest; ten of the 18 patients were also studied during supine leg exercise using a bicycle ergometer. Aortic valvotomy resulted in a significant reduction in the mean left ventricular-aortic pressure gradient and in peak left ventricular systolic pressure with an increase in aortic valve area in most patients. There was an associated increase in the subendocardial blood flow assessed indirectly by the DPTI × O 2 c SPTI ratio. There was a minor increase in the degree of aortic insufficiency in most patients. Although, in general, there was significant hemodynamic improvement, three of the 18 patients still had significant residual stenosis after surgery and another four patients had a major increase in aortic insufficiency. The three patients with residual obstruction and one of the four patients with moderate to severe aortic insufficiency still had a DPTI × O 2 c SPTI ratio of less than 10, suggesting possible residual subendocardial ischemia. Also, the increased left ventricular end-diastolic pressures (LVEDP) present in nearly 50% of the patients before surgery did not change significantly after surgery. Three patients showed an actual increase in LVEDP after surgery. Before surgery, the left ventricular systolic pressure and mean gradient increased on exercise, but this increase was proportionately less than the increase in cardiac output, so that calculated aortic valve area increased on exercise. The DPTI × O 2 c SPTI ratio decreased significantly on exercise, suggesting an increase in myocardial ischemia. Successful surgery resulted in a reduction in left ventricular systolic pressure and mean left ventricular-aortic gradient on exercise, and in improvement in the subendocardial blood flow as assessed by the DPTI × O 2 c SPTI ratio. In general, children with severe aortic stenosis have relatively normal cardiac function on exercise. Some children did show a reduction of stroke index on exercise in spite of rising LVEDP. However, stroke work index increased in all of our children. Adult studies have shown many patients with decrease in stroke work index relative to LVEDP on exercise. The results of pre- and postoperative rest and exercise hemodynamics may be useful in evaluating results of surgery; the postoperative hemodynamic evaluation including the use of DPTI × O 2 c SPTI ratio provides additional useful information which can be used in making decisions concerning exercise activity after surgery.