Preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation for improved valve sizing

Abstract

Objectives: This study sought to evaluate whether supra-aortic angiography during preparatory balloon aortic valvuloplasty (BAV) improves valve sizing.

Background: Current recommendations for valve size selection are based on annular measurements by transesophageal echocardiography and computed tomography, but paravalvular aortic regurgitation (PAR) is a frequent problem.

Methods: Data of 270 consecutive patients with either conventional sizing (group 1, n = 167) or balloon aortic valvuloplasty-based sizing (group 2, n = 103) were compared. PAR was graded angiographically and quantitatively using several hemodynamic indices.

Results: PAR was observed in 113 patients of group 1 and 41 patients of group 2 (67.7% vs. 39.8%, p < 0.001). More than mild PAR was found in 24 (14.4%) patients of group 1 and 8 (7.8%) patients of group 2. According to pre-interventional imaging, 40 (39%) patients had a borderline annulus size, raising uncertainty regarding valve size selection. Balloon sizing resulted in selection of the bigger prosthesis in 30 (29%) and the smaller prosthesis in the remaining patients, and only 1 of these 40 patients had more than mild PAR. As predicted by the hemodynamic indices of PAR, mortality at 30 days and 1 year was less in group 2 than in group 1 (5.8% vs. 9%, p = 0.2 and 10.6% vs. 20%, p = 0.01).

Conclusions: Preparatory balloon aortic valvuloplasty during transcatheter aortic valve implantation improves valve size selection, reduces the associated PAR, and increases survival in borderline cases.

Keywords: AR index; BAV; DAP; DPTI; DPTI:SPTI; LV; LVEDP; MCV; MSCT; Medtronic CoreValve; PAR; SPTI; TAVI; TEE; aortic regurgitation; aortic regurgitation index; balloon aortic valvuloplasty; balloon valvuloplasty; diastolic aortic pressure; diastolic pressure time integral; left ventricular; left ventricular end-diastolic pressure; multislice computed tomography; paravalvular aortic regurgitation; pressure gradient between DAP and LVEDP; ratio of diastolic over systolic pressure time integral; systolic pressure time integral; transcatheter aortic valve implantation; transesophageal echocardiography; ΔP(DAP–LVEDP).