Percutaneous Aortic Valvuloplasty Research Articles

Direct vs. staged TAVI in the acute management of decompensated severe aortic stenosis

Abstract Funding Acknowledgements None. Background Transcatheter aortic valve implantation (TAVI) has emerged as a preferred treatment for severe aortic stenosis across a spectrum of surgical risks, potentially diminishing the role of balloon aortic valvuloplasty (BAV) as a transient solution or a bridge to definitive intervention. With advancements in TAVI technology and expertise, patients even in unstable conditions are increasingly receiving direct, definitive TAVI, avoiding the risks associated with staged, multiple procedures. Aims The study set out to assess whether immediate TAVI is safer and more effective than BAV followed by elective aortic valve replacement (AVR) in acute severe aortic stenosis. Methods Conducted as a retrospective analysis at a single center, this study encompassed a cohort of consecutive patients who received either urgent or emergency BAV, as bridge to AVR, or TAVI to manage decompensated severe aortic stenosis from May 2012 to May 2023. The primary outcomes were mortality rates at both 30 days and one year following the procedures. Results In this cohort, 258 cases of urgent or emergent percutaneous aortic valvuloplasty were evaluated. BAV was performed in 47 patients, whereas 211 received direct TAVI. A significantly higher proportion of the BAV group (36%) was treated due to cardiogenic shock as the primary indication, compared with just 11% in the TAVI group (p< 0.001). Demographic parameters and comorbid condition profiles were equivalently balanced across both groups. The median age was 81 years (interquartile range: 74-85, p= 0.40), and males constituted 56% of the patient population (p= 0.72). Most patients (65%) presented with left ventricular systolic dysfunction, and nearly half (49%) were diagnosed with obstructive coronary artery disease. The reduction in peak aortic valve gradient was significantly more pronounced in the TAVI group (-56±25 mmHg) compared to the BAV group (-27±19 mmHg, p< 0.001). TAVI recipients also had a higher incidence of VARC-2 minor and major bleeding events (26% versus. 6% for BAV, p<0.001), and a greater occurrence of advanced atrioventricular block necessitating temporary pacing (19% vs. 9% for BAV, p= 0.02). Thirty-day survival rates favored the TAVI group (93%) over BAV (86%). This trend persisted at the one-year mark, with survival rates of 84% for TAVI and 70% for BAV. Furthermore, the one-year hazard ratio for mortality among patients undergoing BAV was 2.01 (95% confidence interval: 1.34–3.01, p< 0.001). Conclusion The data from this retrospective analysis indicate that for patients with decompensated severe aortic stenosis, immediate TAVI may confer a mortality benefit over BAV followed by elective procedures. Despite a higher rate of procedural complications, the direct TAVI approach was associated with better survival rates at both 30 days and one year. These outcomes suggest a potential reevaluation of treatment strategies in acute settings may be warranted.

Valvuloplastia aórtica percutánea en la estenosis aórtica severa del adulto: indicaciones y morbimortalidad. Análisis del Registro de valvuloplastias aórticas de un centro cardiovascular universitario

Introduction: severe aortic stenosis is frequent and valve replacement is the only effective treatment. Percutaneous aortic valvuloplasty has transient benefits, and its indication is restricted to unstable patients as a bridge to other treatment or palliative therapy. In our country, there is a few evidence of this technique.Objective: to determine the indication, efficacy, complications and mortality of percutaneous aortic valvuloplasty performed in our center between January 2006 - September 2018. Secondarily, to determine which was the definitive therapy and it´s delay.Method: retrospective and descriptive study. All patients who received valvuloplasty during the study period were included. Clinical histories were reviewed. Qualitative variables were presented in absolute value and percentage; thequantitative ones, in median and interquartile interval. Wilcoxon test was applied to dependent variables, p <0.05. Kaplan Meier curves were performed to analize survival. Protocol was approved by ethics committee.Results: 28 cases. 17 (60.7%) were female. Average age was 79.5 years (IQ 73-85.5). The objective of percutaneous aortic valvuloplasty was bridge therapy to decision in 11 cases (39.2%), bridge to definitive treatment in 12 (42.8%) and palliative in 5 (18%). The most frequent indications were: refractory heart failure in 10 cases (35.7%) and cardiogenic shock in 9 (32.1%). Valvuloplasty was successful in 57.1% of cases. 19 patients died (67.8%). The median survival was 59 days (IQ 5-412). 6 patients received definitive treatment (4 percutaneous implantation and 2 open cardiac surgery). The time from percutaneous aortic valvuloplasty to percutaneous aortic valve implantation was 233 days and 47 days to open surgery.Conclusions: the most frequent indications for percutaneous aortic valvuloplasty were bridge therapy to definitive treatment and decision. Percutaneous aortic valvuloplasty was successful in more than 50% of cases. Major complications determined the prognosis. Mortality was high at follow-up.Asmall number acceded to definitive treatment (predominantly percutaneous implantation).

Efficacy and safety of percutaneous transcatheter aortic valvuloplasty prior to non-cardiac surgery in Japanese patients with severe aortic stenosis

This study aimed to investigate the efficacy of percutaneous transcatheter aortic valvuloplasty (PTAV) performed prior to non-cardiac surgery and the safety of non-cardiac surgery after PTAV in elderly Japanese patients. Between March 2012 and August 2018, 14 patients who underwent PTAVs prior to non-cardiac surgery were enrolled. The mean age was 82.2 ± 7.0 years. A total of 9 patients (64.3%) were women. A retrograde approach was selected for 57.1% of the patients. More than 75% of the procedures were performed using echocardiographic imaging. Echocardiographic data including the aortic valve area (AVA), peak aortic valve blood velocity flow (AVF), peak aortic valve pressure gradient (AVPG), and mean AVPG significantly improved after PTAV (AVA; from 0.54 ± 0.11 to 0.80 ± 0.13 cm2, peak AVF; from 4.6 ± 0.8 to 3.8 ± 0.7 m/s, peak AVG; from 87.9 ± 28.0 to 62.2 ± 19.9 mmHg, mean AVG; from 49.8 ± 18.9 to 35.7 ± 11.6 mmHg; p < 0.001, p < 0.001, p < 0.001, p = 0.0012, respectively). Neither complications related to the PTAV procedure nor procedural mortality were noted. Non-cardiac surgery after PTAV was safely performed; there were no significant adverse events during non-cardiac surgery and no in-hospital mortality occurred after non-cardiac surgery. PTAV prior to non-cardiac surgery in elderly Japanese patients with severe aortic stenosis is safe and effective. In addition, non-cardiac surgery after PTAV can be safety performed without adverse events.

OC14.02: Percutaneous fetal aortic valvuloplasty for critical aortic stenosis: prenatal and postnatal outcomes in the last two years

OC14.02: Percutaneous fetal aortic valvuloplasty for critical aortic stenosis: prenatal and postnatal outcomes in the last two years

Rapid pacing using the 0.035-in. Retrograde left ventricular support wire in 208 cases of transcatheter aortic valve implantation and balloon aortic valvuloplasty.

Transcatheter aortic valve implantation (TAVI) and balloon aortic valvuloplasty (BAV) are now well established percutaneous procedures. These procedures almost always require bursts of rapid ventricular pacing to temporarily reduce cardiac output to facilitate the procedure, usually done via a temporary pacing wire inserted into the right ventricle. We describe a case series of 132 cases of TAVI and 76 BAV done using ventricular pacing via the left ventricular lead by simply connecting one electrode to the patient's skin and one electrode through the left ventricular (LV) wire. All of the 132 TAVI cases (a mixture of Edwards Sapien, Medtronic CoreValve and Boston Scientific Lotus) and 76 BAV were successfully performed using pacing through the LV wire. No BAV patients required temporary pacing wire (TPW) or permanent pacemaker (PPM) insertion. Of the TAVI patients, 6 (4.5%) required TPW during the procedure due to complete heart block to facilitate removal of the LV wire. 1 patient (0.8%) required a PPM urgently due to complete heart block and haemodynamic instability. Twenty eight Patients (21.2%) required PPM following TAVI, 9 of which were within the first 24 hr. Average time to pacemaker implantation was 3.7 days. Rapid ventricular pacing via the LV wire is a simple, safe and effective strategy for percutaneous aortic valve intervention and balloon aortic valvuloplasty. It eliminates the need for a temporary pacing wire with its attendant risks in the vast majority of cases. Furthermore, most pacemakers following TAVI are required late, after the first 24 hr period, by which time the TPW has already usually been removed. © 2016 Wiley Periodicals, Inc.

Salvage transcatheter aortic valve implantation for severe acute aortic regurgitation complicating percutaneous transluminal aortic valvuloplasty

With the advent of transcatheter aortic valve implantation (TAVI), percutaneous transluminal aortic valvuloplasty (PTAV) has experienced a recent renaissance. The roles of PTAV range widely from bridging to definitive therapy to palliation. In general, PTAV is performed without major trouble, but fatal complications including acute aortic regurgitation (AR) are occasionally encountered. We describe a case of severe acute AR complicating PTAV conducted for palliative purposes. Conversion to salvage TAVI bailed out this critical condition. This case demonstrates a new potential use of TAVI.<Learning objective: Acute aortic regurgitation is a rare fatal complication of percutaneous transluminal aortic valvuloplasty. Emergent open heart surgery had been the only treatment option for this complication to date. In our case, we bailed out this critical complication by converting to salvage transcatheter aortic valve implantation (TAVI). This case suggests a new potential use of TAVI.>

大動脈弁狭窄症に対するイノウエ・バルーンによる順行性大動脈弁拡張術 : 周術期および中期観察結果

大動脈弁狭窄症に対するイノウエ・バルーンによる順行性大動脈弁拡張術 : 周術期および中期観察結果

Pregnancy in a Patient With Severe Aortic Stenosis Requiring Unusual Management

IN DEVELOPED COUNTRIES, congenital heart disease is the most common cardiovascular disease reported during pregnancy, with the majority of the cases of aortic stenosis in pregnant women being caused by congenital bicuspid aortic valve. While patients with asymptomatic mild, moderate, or even severe aortic stenosis usually can continue pregnancy to term, all symptomatic patients with severe aortic stenosis or asymptomatic patients with impaired left ventricular function are at high risk for cardiac complications. Aortic valve replacement is indicated before pregnancy in these women. Percutaneous aortic valvuloplasty also can be considered during pregnancy. More invasive techniques, such as aortic valve replacement under normothermic cardiopulmonary bypass during pregnancy, are associated with a high risk of mortality and morbidity for both the mother and the fetus The authors report here a case in which the global management of a pregnant patient with severe aortic stenosis was reconsidered in light of an unexpected echocardiographic report of calcified valves with a high risk of emboli.

開胸手術ハイリスクの維持透析患者における順行性経皮的大動脈弁バルーン形成術 (antegrade percutaneous transluminal aortic valvuloplasty) の有用性

維持透析患者における順行性経皮的大動脈弁バルーン形成術の効果と安全性について検討した. 2009年11月から2014年3月に当院で治療した血液透析患者20例を対象とした. 治療前後で, 大動脈弁圧較差55.6±15.4mmHgから19.0±9.9mmHg, 大動脈弁口面積0.69±0.17cm2から1.24±0.34cm2, NYHA分類3.4±0.68から1.75±0.85, 透析時最低収縮期血圧96.6±22mmHgから112.2±24.9mmHgと改善が認められた. 1例の死亡を認め, その他の合併症は3例で認められた. 再狭窄は2例で認められ, 再治療を行った. 重症大動脈弁狭窄症合併透析患者に対し同治療は低侵襲かつ安全に施行でき, 臨床症状の改善や透析困難の解消に有効であった.

Pop goes the balloon: a cautionary tale in transaortic intervention

This case report and images describe the rare complication of percutaneous aortic valvuloplasty balloon rupture with subsequent mass micro-bubble embolism and haemodynamic collapse. It serves as a cautionary reminder that despite routine standard preparation and technique this adverse event can still occur.

Comparison of two- and three-dimensional transthoracic echocardiography for measurement of aortic annulus diameter in children

Accurate evaluation of aortic root geometry is necessary in congenital aortic valve lesions in children, to guide surgical or angiographical intervention. To compare aortic annulus diameters measured by two- and three-dimensional transthoracic echocardiography (2D- and 3D-TTE), to determine the feasibility and reproducibility of 3D imaging and assess the dynamic changes during the cardiac cycle. Thirty children without heart disease were prospectively included. Two orthogonal aortic annulus diameters were measured offline using multiplanar reconstruction in diastole and in systole and were compared with the measurement of the aortic annulus diameter by 2D-TTE. Mean age was 11±3.6 years. Feasibility of 3D imaging was 100%. The coefficients of intra- and interobserver variability were 3.5% and 6%, respectively. The 2D mean diameter was significantly smaller than the 3D maximum diameter in systole (1.94 vs. 2.01mm; p=0.005). 2D and 3D measurements were well correlated (p<0.0001). The maximum and minimum diameters in 3D were significantly different both in systole and in diastole (p<0.001) underlining an aortic annulus eccentricity. The mean aortic annulus diameters were not significantly different between systole and diastole, with important individual variability during the cardiac cycle. This study demonstrated the feasibility and reproducibility of 3D-TTE for the assessment of the aortic annulus diameter in a normal paediatric population. Because of an underestimation of the maximum diameter by 2D-TTE and the asymmetry of the aortic annulus, 3D measurements could be important before percutaneous aortic valvuloplasty or surgical replacement.

Análise da incidência e preditores clínicos e ecocardiográficos do refluxo paraprotético aórtico após o implante de prótese aórtica transcateter

BACKGROUND: The incidence of paravalvular aortic regurgitation (PAR) seems higher among patients submitted to transcatheter aortic valve implantation and its potential association with an increased late mortality has raised concerns in the scientific community. Our objective was to evaluate the incidence and clinical impact of PAR and establish PAR predictors in our patient population. METHODS: Between July/2009 and February/2013, 112 patients were submitted to transcatheter aortic valve implantation. The degree of PAR after the procedure was assessed according to the VARC 2 criteria. The population was divided into no/mild PAR group and moderate/severe PAR group. RESULTS: Mean age was 82.5 ± 3.9 years, 58.9% were female and the logistic EuroSCORE was 23.6 ± 13.4. There was a decrease in the mean systolic gradient (54.7 ± 15.3 mmHg vs 11.7 ± 4 mmHg; P < 0.01) and a gain in the aortic valve area (0.66 ± 0.15 cm2 vs 1.8 ± 0.3 cm2; P < 0.01). At the end of the procedure 46.4% did not have PAR, and mild or moderate PAR was observed in 42% and 11.6% of the patients. No patient presented severe PAR. Multivariate analysis identified male gender [odds ratio (OR) 5.85, confidence interval (CI] 1.29-26.7; P = 0.022), previous percutaneous aortic val­vuloplasty (OR 18.44, CI 2.30-147.85; P = 0.006), ejection fraction < 35% (OR 4.160, CI 1.014-17.064; P = 0.048) and the presence of severe pulmonary hypertension (OR 7.649, CI 1.86-31.51; P = 0.005) as independent predictors of moderate/severe PAR. CONCLUSIONS: The incidence of moderate/severe PAR was low and comparable to other studies. Male gender, history of prior percutaneous aortic valvuloplasty, presence of severe pulmonary hypertension and severe left ventricular dysfunction were independent predictors of this complication.

Foetal aortic valvuloplasty: experience of five cases

Foetal aortic valvuloplasty has been proposed as a strategy to improve left heart growth and function in foetuses with severe aortic stenosis at risk of progression to hypoplastic left heart syndrome. We report our experience with this intervention. Between 2005 and 2010, five foetuses with aortic stenosis and at risk of progression to hypoplastic left heart syndrome underwent ultrasound-guided percutaneous foetal aortic valvuloplasty. There were no associated maternal complications or foetal demise. In one case, the pregnancy was terminated a couple of weeks after the intervention, one foetus evolved to hypoplastic left heart syndrome, and three did not. Foetal aortic valvuloplasty seems to be a safe and feasible procedure. It has been reported that it has the potential to prevent progression to hypoplastic left heart syndrome in selected foetuses with severe aortic stenosis. Further investigation regarding physiological and clinical aspects of this disease both prenatally and postnatally will probably allow to improve therapeutic strategies and clinical outcome.

Leczenie zwężenia zastawki aortalnej metodą przezskórnej plastyki balonowej w różnych grupach wiekowych

Aortic stenosis is a congenital or acquired reduction in the area of the aortic valve, resulting in obstruction of the blood flow from the left ventricle to the aorta. Aortic stenosis accounts for 2-5% of all congenital heart defects and is a potentially life-threatening disorder. In adults aortic stenosis represents 34% of all valvular heart diseases. Degenerative etiology is present in 80% of cases. Patients with mild aortic stenosis are usually asymptomatic. Symptoms of the disease occur along with the disappearance of effective compensatory mechanisms. These are symptoms of low cardiac output syndrome manifested as fainting, dizziness, ischemic pains, exercise intolerance, arrhythmias with the risk of sudden cardiac death, and heart failure. As soon as the symptoms occur the prognosis significantly worsens, which is associated with a high risk of death. Percutaneous aortic valvuloplasty is a palliative method of treatment of aortic stenosis. The aim of the procedure is to relieve left ventricular outflow tract obstruction, thereby improving cardiac output. The etiology, course of the aortic stenosis and treatment methods, including invasive procedures, vary depending on the patients’ age. The purpose of this paper is to present the characteristics of the aortic valve disease and the strategy of aortic balloon valvuloplasty in different age groups.

Analysis of the Incidence and Clinical and Echocardiographic Predictors of Paravalvular Aortic Regurgitation after Transcatheter Aortic Valve Implantation

ABSTRACT Background The incidence of paravalvular aortic regurgitation (PAR) seems higher among patients submitted to transcatheter aortic valve implantation and its potential association with an increased late mortality has raised concerns in the scientific community. Our objective was to evaluate the incidence and clinical impact of PAR and establish PAR predictors in our patient population. Methods Between July/2009 and February/ 2013, 112 patients were submitted to transcatheter aortic valve implantation. The degree of PAR after the procedure was assessed according to the VARC 2 criteria. The population was divided into no/mild PAR group and moderate/severe PAR group. Results Mean age was 82.5 + 3.9 years, 58.9% were female and the logistic EuroSCORE was 23.6 ± 13.4. There was a decrease in the mean systolic gradient (54.7 ± 15.3 mmHg vs 11.7 ± 4 mmHg; P 2 vs 1.8 ± 0.3 cm 2 ; P Conclusions The incidence of moderate/severe PAR was low and comparable to other studies. Male gender, history of prior percutaneous aortic valvuloplasty, presence of severe pulmonary hypertension and severe left ventricular dysfunction were independent predictors of this complication.

Most Important Outcomes Research Papers on Valvular Heart Disease

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Reviews. This series will summarize the most important manuscripts, as selected by the Editor, which have been published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes as well as general cardiology audience. The studies included in this article represent the most significant research in the area of valvular heart disease. ( Circ Cardiovasc Quality and Outcomes . 2012;5:-e103.) In recent years, no field of clinical cardiology has experienced a great influx of transformational therapeutic options as has the area of valvular heart disease. Treatment of severe aortic stenosis (AS) has been revolutionized by transcatheter aortic valve replacement (TAVR), which has been shown to improve life expectancy and functional outcomes in patients with inoperable AS1,2 and to have short-term outcomes comparable to surgical aortic valve replacement (AVR) in patients at high perioperative risk.3,4 Analogously, mitral valve disease has been amenable to percutaneous valve replacement,5,6 as well as clipping procedures7 that can substantively reduce severe mitral regurgitation (MR) and improve functional outcomes. Even right-sided heart disease involving valves in pulmonary8,9 and tricuspid10 positions has been treated successfully with endovascular techniques. Yet, even with this growing focus on percutaneous valvular interventions, open surgical techniques remain the dominant treatment strategies and standard of care for most advanced lesions. Surgical valve repair and replacement account for 10% to 20% of all cardiac surgical procedures,11–13 approximately two thirds of which are for AS.11–13 For patients undergoing surgery, there remains considerable debate about risk stratification,14 intraoperative technique,15 and postoperative …

Successful treatment of the patient of severe coronary triple vessel disease with severe aortic stenosis by percutaneous transluminal coronary intervention and percutaneous transseptal aortic valvuloplasty

Successful treatment of the patient of severe coronary triple vessel disease with severe aortic stenosis by percutaneous transluminal coronary intervention and percutaneous transseptal aortic valvuloplasty

Percutaneous double valve intervention

An 81-year-old woman was referred for NSTEMI complicated by cardiogenic shock. Urgent invasive assessment revealed a subtotal left anterior descending artery (LAD) stenosis, severe aortic stenosis (mean gradient 60 mmHg, aortic valve area 0.5 cm2), decreased left ventricular (LV) function [left ventricular ejection fraction (LVEF) 49%], grade 3+ mitral regurgitation (MR), and severe pulmonary hypertension. In view of her critical situation, acute LAD–percutaneous coronary intervention and aortic valvuloplasty were performed with …

Immediate and long-term outcome of multiple percutaneous interventions in patients with rheumatic valvular stenosis

We sought to explore the immediate and long-term outcome of combined percutaneous valvuloplasty of the mitral and/or aortic and/or tricuspid valves in a series of patients with rheumatic valvular stenosis.A total of 11 patients (three underwent percutaneous mitral valvuloplasty [PMV], percutaneous aortic valvuloplasty [PAV] and percutaneous tricuspid valvuloplasty [PTV], six underwent PMV and PAV, and two underwent PMV and PTV) were enrolled. PMV was performed by the standard double balloon technique. PAV was always performed after PMV, employing the retrograde approach in eight patients and the antegrade approach in one patient. PTV was performed by the double balloon technique. Echocardiographic assessment was performed before and after the procedures. Follow-up was performed in all patients for a period that ranged from 12 and up to 60 months. PMV was successful in 10 out of 11 cases (91%); PAV was successful in all nine procedures (100%), while PTV was successful in four out of five cases (80%). At long-term follow-up, one case of restenosis occurred following PMV (9%), two following PTV (40%), and no restenosis occurred following PAV.Percutaneous balloon dilatation of rheumatic valvular stenosis is feasible with fairly adequate immediate and long-term outcome.

Use of a low‐profile, compliant balloon for percutaneous aortic valvuloplasty

To determine the safety and immediate efficacy after balloon aortic valvuloplasty (BAV) with a new, low-profile balloon. BAV has a continuing role in the management of high-risk patients with severe aortic stenosis (AS). BAV with traditional noncompliant balloons requires a large femoral arteriotomy and is associated with high rates of access site complications. We retrospectively reviewed medical records of 20 consecutive patients undergoing BAV for severe AS. Retrograde transfemoral BAV was performed with a low-profile, compliant valvuloplasty balloon. Before and after BAV, transaortic gradients were measured invasively and by echocardiography, and aortic valve area (AVA) calculated. Access site complications, functional class and survival were recorded. Patients were 79 +/- 12 years old and had an estimated mortality from open aortic valve replacement of (12.5 +/- 9.6)%. By catheterization, mean aortic gradient fell from 44 +/- 15 to 29 +/- 10 mm Hg (P < 0.001) and AVA increased from 0.63 +/- 0.22 to 0.89 +/- 0.33 cm(2) (P < 0.001). New York Heart Association functional class improved from 3.5 +/- 0.7 to 2.7 +/- 0.8. Procedural mortality was 0%. There were no vascular complications or significant worsening of aortic regurgitation. Transfemoral BAV using a low-profile compliant balloon is feasible with acceptable immediate results and safety.