Percutaneous balloon aortic valvuloplasty in the era of transcatheter aortic valve implantation: a narrative review

Abstract

The role of percutaneous balloon aortic valvuloplasty (BAV) in the management of severe symptomatic aortic stenosis has come under the spotlight following the development of the transcatheter aortic valve implantation (TAVI) technique. Previous indications for BAV were limited to symptom palliation and as a bridge to definitive therapy for patients undergoing conventional surgical aortic valve replacement (AVR). In the TAVI era, BAV may also be undertaken to assess the 'therapeutic response' of a reduction in aortic gradient in borderline patients often with multiple comorbidities, to assess symptomatic improvement prior to consideration of definitive TAVI intervention. This narrative review aims to update the reader on the current indications and practical techniques involved in undertaking a BAV procedure. In addition, a summary of the haemodynamic and clinical outcomes, as well as the frequently encountered procedural complications is presented for BAV procedures conducted during both the pre-TAVI and post-TAVI era.

Keywords: INTERVENTIONAL CARDIOLOGY.

Figure 1

Number of balloon aortic valvuloplasty and TAVI procedures in the UK—the increase in stand-alone BAV mirrors the increase in TAVI (TAVI data from the 25 UK centres with TAVI programmes—British Cardiovascular Intervention Society 2011; BAV data from 14 study centres). Reproduced having obtained permission from corresponding author. BAV, balloon aortic valvuloplasty; TAVI,transcatheter aortic valve implantation.

Figure 2

(A–C) Sequential angiographic images demonstrating placement of the wire, using the retrograde technique in the LV cavity (A), followed by balloon placement (B) and subsequent dilation within the calcified aortic valve (C). LV, left ventricular.

Figure 3

(A and B) Pressure tracings showing haemodynamic results pre-BAV (A) and post-BAV (B) procedure. Pre-BAV, there is a significant transvalvular gradient of 72 mm Hg and haemodynamically significant aortic stenosis. Post-BAV simultaneous aortic-LV pressure assessment demonstrates a significant reduction in transvalvular gradient to 13 mm Hg demonstrating therapeutic efficacy of the BAV. Incidentally, there is a new onset of Left Bundle Branch Block (LBBB) post-BAV in this patient as demonstrated by prolongation of the QRS duration on the rhythm strip on top. This may be a transient phenomenon and rate-related postburst pacing or may be permanent due to anatomical proximity of the AV node and conduction tissue to the aortic annulus. AV, atrioventricular; BAV, balloon aortic valvuloplasty; LV, left ventricular.