Percutaneous Transluminal Aortic Valvuloplasty Research Articles

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.>

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.

Balloon aortic valvuloplasty in children: a multicenter study in Japan.

A questionnaire was used to survey the experience of 8 Japanese institutions with percutaneous transluminal aortic valvuloplasty (PTAV) in children. Among 99 procedures reported in 88 patients, sufficient data for analysis was obtained from 76 procedures in 72 patients. In those 76 procedures the pressure gradient decreased significantly from 68+/-25 (20-140) to 33+/-22 (0-100) mmHg (p<0.01), whereas aortic regurgitation (AR) increased at least one grade in 26 cases (34%). None of the parameters analyzed in this study were predictors of an increase in AR. The reduction in pressure gradient was judged as good in 44 of the 76 procedures (58%). A larger ring diameter, larger balloon diameter and larger ratio balloon diameter/the normal predicted diameter of the aortic valve ring significantly contributed to an effective reduction of pressure gradient. Follow up data (mean interval, 4 years) was available for 26 of 39 clinically effective procedures. AR progressed at least 1 grade in 11 (42%), and the pressure gradient re-developed to more than 50mmHg in 2 cases (8%). In Japan, PTAV has been accepted as a useful procedure for valvular aortic stenosis in children, but progressive AR or re-development of the pressure gradient is not uncommon even after clinically effective PTAV.

Echocardiographic and angiographic evaluation of left ventricular function during percutaneous transluminal aortic valvuloplasty.

Transesophageal echocardiography was used to study the effect of the balloon inflation on left ventricular function in 20 patients with critical aortic stenosis undergoing balloon valvuloplasty. Balloon inflation caused an increase of end-diastolic (15% to 34%) and end-systolic (57% to 72%) left ventricular volume. Left ventricular wall stress increased from 30 +/- 10 x 10(3) dyn/cm2 at diastole and 121 +/- 40 x 10(3) dyn/cm2 at systole to 44 +/- 11 x 10(3) dyn/cm2 and 191 +/- 55 x 10(3) dyn/cm2, respectively, when the balloon was inflated (P less than 0.05). Turbulent regurgitant jet across the mitral valve increased from 15 +/- 2% to 25 +/- 3% during balloon inflation (P less than 0.01). Continued monitoring of left ventricular function after balloon deflation demonstrated prolonged enlargement of left ventricular volumes. Our data show that balloon inflation causes an increase of left ventricular volume and impairment of contraction. Increase of left ventricular wall stress--associated with a reduction of coronary blood flow, due to lower aortic pressure--could result in ischemic myocardial injury.

Aortic valvuloplasty of calcific aortic stenosis with monofoil and trefoil balloon catheters: practical considerations

In order to evaluate the relation between balloon design (monofoil, trefoil) and valvular configuration, experimental aortic valvuloplasty was performed in four post-mortem hearts with calcific aortic stenosis of various morphology. The degree of obstruction of the aortic orifice was assessed by computed axial tomography during inflation of monofoil 15 and 19 mm and trefoil 3 x 12 mm balloon catheters. We also evaluated the hemodynamic repercussion of balloon inflation (fall in systolic aortic pressure) in four elderly patients with acquired aortic stenosis who underwent a percutaneous transluminal aortic balloon valvuloplasty, with stepwise increasing balloon sizes of 15 mm, 19 mm and 3 x 12 mm, as during our in vitro experiments, and who underwent aortic valve replacement later on. In these patients, we correlated the anatomy of the excised aortic valves with the retrospective analysis of aortic pressure curves recorded during previous valvuloplasty procedures. Our experimental and clinicopathological observations showed that the degree of obstruction of the aortic orifice in post-mortem specimens and the tolerance to balloon inflation in live patients are dependent of the valvular configuration. Although trefoil balloons have the theoretical advantage to avoid complete obstruction of the aortic orifice during inflation, we observed that in presence of a tricuspid configuration, they could be potentially more occlusive than monofoil balloons since each of the 3 individual components of the trefoil balloon occupied the intercommissural spaces while inflated. However, they offered more residual free space when inflated in aortic valves with a bicuspid configuration (i.e. congenitally bicuspid valves or tricuspid valves with one fused commissure). In our opinion, these observations are relevant, since degenerative disease of the aortic valve (i.e. tricuspid valve without commissural fusion) is now recognized as the most common etiology of aortic stenosis in the elderly.

Percutaneous transluminal aortic valvuloplasty— The acute outcome and follow-up of 149 patients who underwent the double balloon technique

Double balloon percutaneous transluminal aortic valvuloplasty (PTAV) was performed on 149 patients (76 male (51%), mean age 76 +/- 11 years) whose symptoms included severe congestive heart failure in 127 cases (82%), syncope in 21 (14%) and angina in six (4%). Significant changes (P less than 0.05) in peak systolic (83 +/- 36 to 38 +/- 30 mmHg) and mean gradient (68 +/- 25 to 36 +/- 21 mmHg), and aortic valve area (0.6 +/- 0.2 to 1.0 +/- 0.4 cm2) were achieved in 130/149 patients (87%). Complications included an overall in-hospital mortality of 13%, (10.0% excluding the six deaths occurring in 18 moribund patients), a neurologic deficit incidence of 3%, and surgical arterial entry site repair 3.0% (14/47) of patients. Multivariate analysis identified congestive heart failure (NYHA Class IV), left ventricular ejection fraction, cardiac output and coronary artery disease as independent variables significantly affecting in-hospital mortality. Predictors of poor long-term survival were degree of heart failure, and coronary artery disease. The cumulative probability of survival at 24 months was 52 +/- 5% (excluding non-cardiac deaths, was 66 +/- 3%). Follow-up (mean time: 16 +/- 7 months) of 130 patients discharged alive revealed 41 late deaths (26 cardiac related). Sixty-two patients (70%) were symptomatically improved; 17 patients had symptom recurrence and underwent repeat valvuloplasty, and 10 patients valve replacement. Follow-up catheterization of 18 asymptomatic patients revealed that 11 patients had silently restenosed. These data indicate that aortic valvuloplasty is a palliative therapy for elderly patients, who are poor surgical candidates, with symptomatic calcific aortic stenosis with reasonable clinical success and long-term survival when considering their clinical status, but with a significant restenosis rate.

Transcranial Doppler Monitoring During Percutaneous Transluminal Aortic Valvuloplasty

Cerebral blood flow was studied in 12 elderly patients with severe calcific aortic stenosis by means of transcranial Doppler sonography (TCD) during percutaneous transluminal aortic valvuloplasty (PTAV). In 8 of these 12 patients duplex sonography revealed a stenosis of the internal carotid artery (ICA) exceeding 50%. Frequency spectra of 10 patients showed a satisfactory quality and were analyzed. In 7 subjects balloon inflation was well tolerated and systolic blood pressure did not drop below 75 mmHg. In these patients, whether they had a stenosis of the ICA or not, blood flow velocity in the middle cerebral artery (MCA) did not decrease to a critical level. The authors defined "critical" as a reduction of mean blood flow velocity in the MCA exceeding 50% or a decrease below 35 cm/sec. Three patients showed a rapid decrease of systolic aortic pressure below 75 mmHg. In these subjects mean blood flow velocity in the MCA dropped to levels below 35 cm/sec. Deflation and retraction of the balloon resulted in a rapid increase of systemic blood pressure and flow velocity in the MCA. This report demonstrates TCD to be a useful monitoring method of determining residual perfusion in patients with aortic stenosis during PTAV.

Assessment of the “long sheath” technique for percutaneous aortic balloon valvuloplasty

A 100 cm-long 16.5 F valvuloplasty catheter introducer was assessed as an adjunct for percutaneous transluminal aortic valvuloplasty (PTAV) via the femoral artery in 31 patients with severe aortic stenosis. Observed improvements in peak systolic gradient (81.6 +/- 29.9 mm Hg vs. 35.5 +/- 16.0 mm Hg, P less than 0.000001) and aortic valve area (0.6 +/- 0.4 cm2 vs. 1.0 +/- 0.6 cm2, P less than 0.00001) were similar to those achieved in a control group (C) of 17 patients in which no femoral sheath was used. However, a shorter procedure duration (211 +/- 81 min vs. 117 +/- 30 min, P less than 0.001) and a reduced rate of vascular complications at the femoral puncture site (41% vs. 6.5%) were observed in patients in whom the long sheath (LS) technique was used. The frequency of other PTAV-related complications was comparable (C = 35%, LS = 29%, P = n.s.). Other technical advantages of this device are: 1) prevention of looping and bending of the balloon catheter in tortuous vessels and easy positioning of the balloon across the aortic orifice provided by the LS trackability, 2) stabilisation of the balloon during inflation, 3) monitoring of supravalvular aortic pressure provided by the side-arm of the LS and reliable measurement of systolic gradient, and 4) the ability to perform aortograms without the need of another catheter in the ascending aorta. Thus, in our experience, the long sheath technique is a valuable adjunct for PTAV.

Percutaneous transluminal aortic valvuloplasty: Acute outcome and follow-up of 125 patients

Percutaneous transluminal aortic valvuloplasty was performed on 125 patients (59 men [47%], mean age 76 ± 13 years) between July 1986 and May 1988, with presenting symptoms of severe congestive heart failure in 88 (70%), moribund state in 15 (12%) and syncope in 17 (14%). Surgical valve replacement was considered unsuitable in 79% of cases. A multiple balloon technique was utilized in 119 patients (95%).Valvuloplasty produced significant changes in peak pressure gradient (87 ± 38 to 32 ± 17 mm Hg), mean pressure gradient (70 ± 26 to 30 ± 13 mm Hg) and valve area (0.6 ± 0.2 to 1.0 ± 0.3 cm2). Complications included: in-hospital mortality in 10% (6 of 13 deaths in moribund patients), neurologic deficit in 3% and myocardial infarction in 2%. Arterial repair was required at 12 (4%) of 325 entry sites.Multivariate analysis identified severe congestive heart failure, preprocedure left ventricular ejection fraction and cardiac output as the only independent variables significantly affecting mortality. The cumulative probability of survival at 12 months was 62 ± 6% and, excluding noncardiac deaths, was 77 ± 5%. At a mean of 12 ± 4 months' follow-up, 55 of 72 patients were symptomatically improved; 10 patients with symptom recurrence underwent repeat valvuloplasty and 5 had valve replacement. Cardiac catheterization was repeated in 12 symptomatically improved patients, 9 of whom had valve restenosis.These data indicate that aortic valvuloplasty should be considered a palliative therapy for elderly patients with symptomatic calcific aortic stenosis who are poor surgical candidates.

Stimulation of atrial natriuretic peptide and vasopressin during percutaneous transluminal aortic valvuloplasty

The objective of this study was to determine the effects of transient aortic valve occlusion (balloon valvuloplasty) on vasoactive hormones in patients with heart failure. Plasma atrial natriuretic peptide, vasopressin, aldosterone, adrenocorticotropic hormone (ACTH), and plasma renin activity were measured before, immediately after, and 30 minutes and 18 to 24 hours following balloon inflation in 18 patients. Mean right atrial and pulmonary wedge pressures were 6 and 18 mm Hg before inflations, respectively, and were unchanged after balloon inflations (5 and 13 mm Hg, respectively). Systemic systolic/diastolic pressures were 139 ± 8 65 ± 4 mm Hg before occlusion, decreased to 47 ± 5 34 ± 3 mm Hg during occlusion, and returned to baseline after occlusions. Baseline atrial natriuretic peptide levels were 267 ± 43 pg/ml and increased to 513 ± 71 pg/ml after balloon inflations. Vasopressin levels before occlusion were 9.1 ± 2.2 pg/ml and increased to 21.4 ± 4.8 pg/ml after balloon inflations. Plasma renin activity was 5.4 ± 1.4 ng/ml/hr before inflations and was not significantly changed after balloon inflations. No clinically significant changes in plasma sodium, potassium, creatinine, and osmolality were observed after the procedure. Aldosterone increased from 23 ± 4 to 40 ± 7 ng/dl 10 minutes after the last inflation. Plasma ACTH measured in seven patients with increased aldosterone was 28 ± 8 pg/ml before and increased to 295 ± 157 pg/ml 10 minutes after balloon inflations. The increases in natriuretic peptide and vasopressin were likely due to elevated intracardiac and decreased arterial pressures, respectively; they persisted in spite of no clinically significant changes in filling pressures 12 to 24 hours after the procedure. Increased aldosterone secretion with no change in renin was likely due to elevated ACTH levels and may have attenuated the hyponatremic effects of atrial natriuretic peptide and vasopressin.

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.

Treatment of calcified aortic stenosis: surgery or percutaneous transluminal aortic valvuloplasty?

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62 +/- 12 years, 71.7% were in NYHA class III or IV), 68.8% received mechanical prostheses, and in 11.8% a bypass graft was associated. The operative mortality was 6.9% (4% since 1983). The mean follow-up was 57.6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6.2% since 1983, and the actuarial survival rate was 67.5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79 +/- 5 years, 93% in Class III or IV). Immediate mortality was 7.1%. The morbidity was due to tamponade (1.8%), myocardial infarction (3.6%), vascular trauma (5.3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4.2 +/- 3, range 1-14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0.49-0.75 cm2; P less than 0.0001) and these findings were corroborated by Doppler study (0.46-0.70 cm2, P less than 0.001). In conclusion, this series shows that surgery provides satisfactory results in AS with a low mortality and good long-term results, even in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal aortic valvuloplasty: indications and results in adult aortic stenosis.

Journal Article Percutaneous transluminal aortic valvuloplasty: indications and results in adult aortic stenosis Get access A. Cribier, A. Cribier Service des Soins Intensifs Cardiologiques et des Explorations Hémodynamiques Cardiovasculaires, Centre Hospitalier et Universitaire, Hôpital Charles Nicolle1 rue de Germont, 76000 Rouen, France Search for other works by this author on: Oxford Academic PubMed Google Scholar J. Berland, J. Berland Service des Soins Intensifs Cardiologiques et des Explorations Hémodynamiques Cardiovasculaires, Centre Hospitalier et Universitaire, Hôpital Charles Nicolle1 rue de Germont, 76000 Rouen, France Search for other works by this author on: Oxford Academic PubMed Google Scholar R. Koning, R. Koning Service des Soins Intensifs Cardiologiques et des Explorations Hémodynamiques Cardiovasculaires, Centre Hospitalier et Universitaire, Hôpital Charles Nicolle1 rue de Germont, 76000 Rouen, France Search for other works by this author on: Oxford Academic PubMed Google Scholar J. P. Bellefleur, J. P. Bellefleur Service des Soins Intensifs Cardiologiques et des Explorations Hémodynamiques Cardiovasculaires, Centre Hospitalier et Universitaire, Hôpital Charles Nicolle1 rue de Germont, 76000 Rouen, France Search for other works by this author on: Oxford Academic PubMed Google Scholar R. Mechmeche, R. Mechmeche Service des Soins Intensifs Cardiologiques et des Explorations Hémodynamiques Cardiovasculaires, Centre Hospitalier et Universitaire, Hôpital Charles Nicolle1 rue de Germont, 76000 Rouen, France Search for other works by this author on: Oxford Academic PubMed Google Scholar B. Letac B. Letac Service des Soins Intensifs Cardiologiques et des Explorations Hémodynamiques Cardiovasculaires, Centre Hospitalier et Universitaire, Hôpital Charles Nicolle1 rue de Germont, 76000 Rouen, France Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, Volume 9, Issue suppl_E, April 1988, Pages 149–154, https://doi.org/10.1093/eurheartj/9.suppl_E.149 Published: 01 April 1988

Inoperable aortic stenosis in the elderly: benefit from percutaneous transluminal valvuloplasty.

Eight patients with severe symptomatic calcific aortic stenosis were considered to be unsuitable for valve replacement. Four were admitted with pulmonary oedema and three in cardiogenic shock and one had angina at rest. With the use of echocardiographic and radiographic guidance percutaneous transluminal aortic valvuloplasty was carried out. Aortic gradients were reduced by an average of 40%. All four patients who presented with cardiac failure improved immediately and remained well six months later. The patient with angina was symptom free at nine months. Two of the three patients who presented in cardiogenic shock improved immediately and were well nine and three months later. The other patient died four hours after the procedure. Doppler echocardiographic studies showed a slight initial increase in aortic incompetence, but this did not worsen and valvar gradients remained improved three and six months later. Percutaneous valvuloplasty of the aortic valve is an effective therapeutic option in patients with severe calcific aortic stenosis who are unfit for surgery. Its role as an alternative to surgery has not been considered and should be investigated in a controlled clinical trial.