Gradient reduction, aortic valve regurgitation and prolapse after balloon aortic valvuloplasty in 32 consecutive patients with congenital aortic stenosis

From 1986 to 1988, balloon aortic valvuloplasty was performed in 32 patients with congenital valvular aortic stenosis. The patients ranged in age from 2 days to 28 years (mean +/- SD 8.3 +/- 5.9). One balloon was used in 17 patients and two balloons were used in 15 patients. Immediately after valvuloplasty, peak systolic pressure gradient across the aortic valve decreased significantly from 77 +/- 27 to 23 +/- 16 mm Hg (p less than 0.01), a 70% reduction in gradient. At early follow-up study (4.1 +/- 3.3 months after valvuloplasty), there was a 48 +/- 20.5% reduction in gradient compared with that before valvuloplasty, and at late follow-up evaluation (19.2 +/- 5.6 months), a reduction in gradient of 40 +/- 29% persisted. Echocardiography showed evidence of significantly increased aortic regurgitation in 10 patients (31%) and aortic valve prolapse in 7 patients (22%). There was no correlation between the balloon/anulus ratio and the subsequent development of aortic regurgitation or prolapse. In fact, no patient who showed a significant increase in aortic regurgitation had had a balloon/anulus ratio greater than 100%. It is concluded that balloon aortic valvuloplasty effectively reduces peak systolic pressure gradient across the aortic valve in patients with congenital aortic stenosis. However, subsequent aortic regurgitation and prolapse occur in a significant number of patients, even if appropriate technique and a balloon size no greater than that of the aortic anulus are used.     

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.     

Percutaneous balloon aortic valvuloplasty in adults with calcific aortic stenosis

After 5 years' experience with percutaneous balloon aortic valvuloplasty and more than 550 patients dilated for calcific aortic stenosis in our series, the limits of the method are well recognized, and the indications have been reviewed. To date, the two main indications are very old patients with increased surgical risks and critically ill patients in whom the procedure is most often used as a bridge to surgery. From our series of 180 octogenarians and nonagenarians with several factors increasing the predicted perioperative mortality, we showed that the technique is able to efficiently palliate the symptoms and improve survival. Valve replacement remains, however, recommended in otherwise healthy and active elderly patients. Balloon aortic valvuloplasty is also clearly useful in critically ill patients with major left ventricular dysfunction and severe heart failure, especially in patients with cardiogenic shock in whom it may be life saving. A dramatic improvement of left ventricular function is most generally obtained, allowing valve replacement to be performed later with an acceptable lowered risk. Balloon aortic valvuloplasty, a low-cost and low-risk procedure in experienced hands, requiring only local anesthesia and a short hospitalization stay, partially reduces aortic stenosis but may in many cases be the only valuable therapeutic option for patient improvement.     

Successful aortic balloon valvuloplasty in critical aortic stenosis with shock

Emergency balloon valvuloplasty was performed in a 42 year old male with critical aortic stenosis, severe congestive heart failure, and shock. Hemodynamic and clinical improvement occurred and he underwent elective aortic valve replacement. Balloon aortic valvuloplasty may provide a “bridge” to aortic valve replacement in patients with critical aortic stenosis and shock. © 1993 Wiley-Liss, Inc.     

Changes in mitral regurgitation after balloon aortic valvuloplasty

The coexistence of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) is not infrequent and has been associated with adverse outcome. The aims of this study were to evaluate the change in MR severity and to identify the correlates of MR improvement in patients with severe AS and moderate to severe MR who underwent balloon aortic valvuloplasty (BAV). Patients with severe AS and at least moderate MR who underwent their first BAV procedures (n = 74) were divided into 2 groups: patients with improved- (n = 34 [46%]) and those without improved (n = 40 [54%]) MR after BAV on transthoracic echocardiography. The population had a mean age of 84 years and was more frequently female (63.5%), with a high risk profile (mean Society of Thoracic Surgeons score 15%, mean European System for Cardiac Operative Risk Evaluation score 57%). Baseline characteristics were balanced between the 2 groups. Patients with improved MR after BAV had smaller left atrial dimensions (45 ± 7 vs 49 ± 7 mm, p = 0.01) and lower peak aortic velocities (3.7 ± 0.6 vs 4.0 ± 0.8 m/s, p = 0.05) and mean transaortic valve gradients (33.2 ± 12.1 vs 40.6 ± 17.4 mm Hg, p = 0.05) at baseline. Left atrial dimension [odds ratio (OR) 3.37, p = 0.006], left ventricular end-diastolic dimension (OR 2.7, p = 0.04), and mean transaortic valve gradient (OR 1.04, p = 0.05), but not left ventricular systolic function or functional MR, were correlated with MR improvement by logistic regression analysis. In conclusion, nearly half of the patients with severe AS and coexistent MR showed improvement in the magnitude of MR after BAV. Larger left atrial and left ventricular end-diastolic dimensions and higher transaortic valve gradients were associated with lack of MR improvement.     

Management of pediatric patients with isolated valvar aortic stenosis by balloon aortic valvuloplasty

Moderate to severe aortic stenosis in children requires an initial procedure to improve the stenosis and often additional procedures for recurrent stenosis or aortic insufficiency before adulthood. The purpose of this study was to evaluate children who underwent balloon valvuloplasty and were followed with a specific management plan. Twenty-two children with aortic stenosis underwent balloon valvuloplasty and were followed on a regular basis. Repeat valvuloplasty was performed if indicated. The initial gradient was reduced from 63 ± 9 mmHg to 28 ± 8 mmHg (P<0.001). There were no deaths and only one major complication, which had no sequelae. Average follow-up was 61 ± 23 months. Three patients required valve replacement 39–76 months after valvuloplasty for progressive insufficiency. Seven patients underwent successful repeat valvuloplasty. The overall probability of survival without surgical intervention was 75% at 100 months. Balloon valvuloplasty is an effective intermediate palliation for aortic stenosis and is an acceptable alternative to surgical valvotomy. Repeat valvuloplasty is successful without additional risk. In a subgroup of patients, aortic insufficiency is progressive and will require surgical intervention. © 1996 Wiley-Liss, Inc.     

Transient acute severe aortic regurgitation complicating balloon aortic valvuloplasty

Transient, acute severe aortic regurgitation documented by hemodynamic and Dopplerechocardiographic assessment was observed in an elderly woman immediately following balloon aortic valvuloplasty for critical aortic stenosis. Aortic regurgitation responded to medical therapy and resolved within 24 hr. Potential mechanisms are discussed. We suspect that an oversized balloon to aortic ring area stretched the annulus, separating the valve cusps and resulting in severe regurgitation, which rapidly normalized.     

Percutaneous balloon valvuloplasty in neonates with critical aortic stenosis

Percutaneous balloon valvuloplasty was attempted in 10 newborn infants with critical aortic valve stenosis and severe congestive heart failure. Three had a very small left ventricle and aortic anulus. In one infant, the aortic valve could not be passed, and in another infant, a technical error resulted in severe valvular damage, aortic insufficiency and death. Among the eight patients who had effective dilation, the stenosis was relieved in seven as assessed by a significant decrease in transvalvular pressure gradient, improvement of left ventricular contraction and eventual inversion of the ductal shunting. The procedure failed in the only patient whose dilation was performed with an undersized balloon. Aortic insufficiency occurred in three infants and was severe (perforated cusp) in one, moderate in one whose valve was dilated with an excessively large balloon and mild and transient in one. None of the three infants with a very small left ventricle recovered (two died and one underwent cardiac transplantation). Among the seven infants with a left ventricle of acceptable size, three underwent subsequent aortic valvotomy; one of these died and two bad good results. The remaining four are doing well 16 +/- 5 months later (mean +/- SD) with mild to moderate residual aortic stenosis and normal left ventricular function. In conclusion, percutaneous balloon valvuloplasty is an acceptable alternative to surgery in neonates with critical aortic valve stenosis. Incidence of complications and good relief of the obstruction depend on a careful technique. Immediate results are similar to those of surgery. Late prognosis depends on the quality of the left heart structures.     

Emergency balloon aortic valvuloplasty in patients with critical aortic stenosis presenting with cardiogenic shock.

This report describes 2 cases of aortic valvuloplasty performed as emergency treatment in patients with critical aortic stenosis presenting with cardiogenic shock. This procedure can be life-saving, and allows the patients to undergo further evaluation for aortic valve replacement, or other definitive treatments such as the recently developed percutaneous heart valve implantation for patients with unacceptably high surgical risk.     

Combined aortic and mitral balloon valvuloplasty in patients with critical aortic and mitral valve stenosis: Results in six cases

Six patients with severe combined aortic and mitral valve stenosis underwent double valve balloon dilation as an alternative to surgical valve replacement. Cardiac catheterization in all patients before valve dilation revealed heavily calcified aortic and mitral valves with severe stenosis and minimal regurgitation. Balloon aortic valvuloplasty was performed in each patient with a 20 mm balloon dilation catheter passed retrograde through the aortic valve whereas mitral valvuloplasty was performed transseptally with either a single or double balloon technique.After dilation, the mean aortic and mitral gradients decreased in all patients, with the area of the aortic and the mitral valve increasing from 0.5 ± 0.3 to 0.9 ± 0.3 cm²and from 0.7 ± 0.1 to 1.5 ± 0.7 cm², respectively. The procedures were well tolerated, with no embolic events and no significant increase in valvular regurgitation, and resulted in a reduction in symptoms of dyspnea on exertion and weakness in all patients that has persisted for an average of 5.7 months of follow-up in five of the six patients.It is concluded that combined dilation of stenotic aortic and mitral valves can be accomplished percutaneously and may be considered for patients with combined valvular stenosis who refuse or are deferred from surgical intervention.     

Results of balloon valvuloplasty in pulmonary valve stenosis

Percutaneous balloon pulmonary valvuloplasty was performed in 17 consecutive patients, ranging in age from eleven years to 67 years (mean age: 40 +/- 17 years). The peak to peak pressure gradient was reduced by 16 to 167 mm Hg, the mean pressure gradient decreased from 99 +/- 42 to 46 +/- 22 mm Hg. In six patients there was a pressure gradient above 50 mm Hg after the procedure. Within three months it decreased due to regression of infundibular hypertrophy and ranged from 26 to 46 mm Hg after one year. There were no serious complications. One patient experienced a brief episode of syncope. Another patient developed a pulmonary incompetence which was without hemodynamic significance. Percutaneous balloon pulmonary valvuloplasty offers an alternative method for treating pulmonary stenosis not only in children but also in adults.     

Twenty-five year experience with balloon aortic valvuloplasty for congenital aortic stenosis

Balloon aortic valvuloplasty (BAV) is the primary therapy for congenital aortic stenosis (AS). Few reports describe long-term outcomes. In this study, a retrospective single-institution review was performed of patients who underwent BAV for congenital AS. The following end points were evaluated: moderate or severe aortic insufficiency (AI) by echocardiography, aortic valve replacement, repeat BAV, surgical aortic valvotomy, and transplantation or death. From 1985 to 2009, 272 patients who underwent BAV at ages 1 day to 30.5 years were followed for 5.8 ± 6.7 years. Transplantation or death occurred in 24 patients (9%) and was associated with depressed baseline left ventricular shortening fraction (LVSF) (p = 0.04). Aortic valve replacement occurred in 42 patients (15%) at a median of 3.5 years (interquartile range 75 days to 5.9 years) after BAV and was associated with post-BAV gradient ≥25 mm Hg (p = 0.02), the presence of post-BAV AI (p = 0.03), and below-average baseline LVSF (p = 0.04). AI was found in 83 patients (31%) at a median of 4.8 years (interquartile range 1.4 to 8.7) and was inversely related to post-BAV gradient ≥25 mm Hg (p <0.04). AI was associated with depressed baseline LVSF (p = 0.02). Repeat valvuloplasty (balloon or surgical) occurred in 37 patients (15%) at a median of 0.51 years (interquartile range 0.10 to 5.15) and was associated with neonatal BAV (p <0.01), post-BAV gradient ≥25 mm Hg (p = 0.03), and depressed baseline LVSF (p = 0.05). In conclusion, BAV confers long-term benefits to most patients with congenital AS. Neonates, patients with post-BAV gradients ≥25 mm Hg, and patients with lower baseline LVSF experienced worse outcomes.     

Aortic balloon valvuloplasty before transcatheter valve replacement in high-risk patients with aortic stenosis

Background

Balloon aortic valvuloplasty (BAV) has been revived as a bridge to transcatheter aortic valve replacement (TAVR). The aim of the current prospective study was to define a safe time period from BAV to TAVR and to determine hemodynamic variables that predict event-free survival after BAV.

Patients and methods

The present prospective study included 68 consecutive patients with severe aortic stenosis who were treated initially with BAV from 2009 to 2012. Echocardiographic and invasive hemodynamic assessments were performed before BAV. The patients were followed up at regular intervals and events were defined as cardiac hospitalization or death.

Results

Invasive hemodynamic evaluation yielded more favorable results than echocardiographic assessment: aortic stenosis was less severe, cardiac output was higher, and pulmonary capillary wedge pressure (PCWP) was lower. Post-BAV event-free survival was 80.4?% at 30 days, 64.5?% at 6 months, 37?% at 1 year, 22.3?% at 2 years, and 9.3?% at 3 years. After excluding pre-discharge deaths (n?=?7), the 30-day event-free survival rate was 90?%. Predictors of events after BAV were atrial fibrillation, cardiogenic shock, elevated euroSCORE (European System for Cardiac Operative Risk Evaluation), elevated PCWP, and elevated pulmonary artery systolic pressure. Invasively measured PCWP was the only independent predictor of events (hazard ratio, 1.07; 95?% confidence interval, 1.03–1.11; p?=?0.001).

Conclusion

A 30-day post-BAV period may be considered a bridge to TAVR. Furthermore, invasive assessment of PCWP before BAV is an independent hemodynamic predictor of events after BAV.

     

经皮二尖瓣球囊扩张术治疗二尖瓣狭窄伴中度返流

目的　探讨经皮二尖瓣球囊扩张术 (PBMV)治疗二尖瓣狭窄 (MS)伴中度二尖瓣返流(MR)的近、远期疗效。方法　采用自制二尖瓣球囊导管治疗MS伴中度MR患者 6 2例 ,其中二尖瓣膜明显增厚、钙化者 7例 ,对左室最大前后径、二尖瓣口面积、左房平均压、二尖瓣跨瓣压差及心功能(NYHA分级 )等主要指标随访观察 12～ 36个月。结果　术后二尖瓣口面积明显增大 [(0 83± 0 18)cm2 比 (1 86± 0 2 4 )cm2 ,P <0 0 1],左房平均压 [(32± 8)mmHg比 (13± 8)mmHg ,P <0 0 1,1mmHg=0 133kPa]及二尖瓣跨瓣压差 [(18± 9)mmHg比 (5± 3)mmHg ,P <0 0 1]明显降低 ,心功能明显改善 [(2 81± 0 2 4 )级比 (1 4 6± 0 37)级 ,P <0 0 1],左室最大前后径无显著改变 [(4 5± 4 )mm比 (4 6± 4 )mm ,P >0 0 5 ]。对左室最大前后径、二尖瓣口面积及心功能等指标随访观察 12～ 36个月均无明显改变。结论　选择合适病例 ,严格把握球囊扩张终点 ,风湿性二尖瓣狭窄并中度返流患者PBMV的近、远期疗效显著。     

Results of repeat balloon valvuloplasty for treatment of aortic stenosis in patients aged 59 to 104 years

Balloon aortic valvuloplasty (BAV) may be considered a palliative procedure that is performed in patients who have severely symptomatic aortic stenosis and a prohibitive surgical risk. However, due to poor early survival rates, most previous studies have involved a single BAV procedure. We analyzed long-term outcomes in patients who had severe aortic stenosis and BAV that incorporated repeat procedures to maintain symptom relief and increase survival rate. We retrospectively analyzed 212 consecutive nonsurgical patients (59 to 104 years old) who had severe calcific aortic stenosis and underwent 282 cumulative BAV procedures. Demographic, procedural, and follow-up mortality data were collected. BAV was performed with single or incremental balloon dilatation to obtain a postprocedural transaortic gradient close to 1/3 of the baseline gradient. Peak transaortic gradient after BAV decreased from 55 +/- 22 to 20 +/- 11 mm Hg and aortic valve area increased from 0.6 +/- 0.2 to 1.2 +/- 0.3 cm(2). Mean follow-up duration was 32 +/- 18 months. During follow-up, 24% of patients underwent a second BAV and 9% of patients underwent a third BAV. Duration of symptom alleviation after the first, second, and third BAV procedures were 18 +/- 3, 15 +/- 4, and 10 +/- 3 months, respectively. Median survival rate after BAV was 35 months. Survival rates 1, 3, and 5 years after the procedure were 64%, 28%, and 14% respectively. Patients who underwent repeat BAV had higher 3-year survival rates than did patients who underwent 1 BAV (p = 0.01). Therefore, repeat BAV is a viable treatment strategy in nonsurgical patients who have severe calcific aortic stenosis, because it provides a median survival rate of approximately 3 years and maintains clinical improvement.     

Treatment of calcific aortic stenosis by balloon valvuloplasty

Recent reports have established the feasibility of using balloon valvuloplasty to reduce left ventricular outflow tract obstruction due to a calcified aortic valve. The present study summarizes experiences with this technique in 9 patients (7 women, 2 men, mean age 78 years) in whom balloon valvuloplasty was used to treat calcific aortic stenosis. Peak aortic valve gradient (mm Hg) decreased from 68 +/- 8 (mean +/- standard error of the mean) before valvuloplasty to 35 +/- 5 after valvuloplasty (p = 0.003). Mean aortic valve gradient decreased from 57 +/- 7 before valvuloplasty to 30 +/- 5 after valvuloplasty (p = 0.006). Calculated aortic valve area increased from 0.42 +/- 0.04 to 0.81 +/- 0.06 cm2 (p = 0.005). Balloon valvuloplasty failed to diminish aortic valve obstruction in only 1 patient who, at subsequent surgery, had a congenitally bicuspid aortic valve. Significant aortic regurgitation was not observed in any of the 9 patients after valvuloplasty. One patient did have a highly focal, presumably embolic, brain stem infarct during the procedure. Femoral arterial blood loss, related to wire-guided exchange of balloon catheters too large for a 12Fr introducer sheath, was minimized by direct arterial exposure in 8 of the 9 patients. Thus, these findings confirm the efficacy of balloon valvuloplasty for the treatment of calcific aortic stenosis. The procedure, however, is not without hazard.     

过渡性经皮球囊主动脉瓣成形术治疗危重主动脉瓣狭窄的早期效果

目的 探讨过渡性经皮球囊主动脉瓣成形术(PBAV)治疗暂时不宜行外科主动脉瓣置换术和经导管主动脉瓣置入术(TAVR)危重主动脉瓣狭窄患者的早期临床结果.方法 回顾性分析2011年3月至2014年1月在阜外心血管病医院行过渡性PBAV的20例危重主动脉瓣狭窄患者的临床资料,患者年龄(72 ±8)岁.观察手术相关并发症及疗效,并在术后对患者进行随访.结果 所有患者均完成PBAV,主动脉瓣瓣口面积从术前的(0.55±0.09) m2增大至(0.77±0.15)m2,主动脉瓣跨瓣压差从术前的(49.5±15.0) mmHg(1 mmHg =0.133 kPa)降至术后的(31.7±12.0) mmHg(P＜0.001),左心室射血分数从术前的(31.7±9.0)％增加至术后的(39.0±11.0)％ (P =0.018),肺动脉收缩压从术前的(55.1±18.0)mmHg降至术后的(38.7±11.0)mmHg(P =0.025),主动脉瓣反流分级手术前后差异无统计学意义(P=0.854).术后发生低血压4例,一过性左束支传导阻滞5例,术后24 h和30 d分别死亡1例和3例患者.术后30 d内,5例患者实施外科主动脉瓣置换术,1例实施TAVR,5例等待TAVR.结论 对于不宜行外科主动脉瓣置换术和TAVR的危重主动脉瓣狭窄患者,PBAV可取得良好的早期临床结果,有望成为一种安全的过渡性治疗手段.     

Percutaneous Inoue-balloon valvuloplasty in patients with mitral stenosis and associated moderate mitral regurgitation

The present study compares the outcome of percutaneous Inoue-balloon mitral valvuloplasty performed in 21 patients with (group A) and 83 patients without (group B) preexisting moderate mitral regurgitation, using our height-derived balloon-sizing method. All procedures were successfully completed without untoward complications. The immediate increments in mitral valve area measured by echocardiographic methods and optimal valvuloplasty results were significantly higher in group B compared with group A (0.9 cm² vs. 0.7 cm², P = 0.01, and 99% vs. 90%, P = 0.007, respectively). No patients in either group sustained a final grade ≥¾ angiographic mitral regurgitation. A mild increase in mitral regurgitation was encountered more commonly in group B than in group A patients (22% vs. 0%, P = 0.03). At a mean follow-up of 19–20 months, the substantial majority of patients (≥90%) in both groups continued to experience maintained symptomatic benefits. In conclusion, our preliminary data seem to indicate that percutaneous Inoue-balloon mitral valvuloplasty using our height-derived balloon-sizing method in the stepwise dilatation approach in selected patients with significant mitral stenosis and concomitant moderate mitral regurgitation is associated with a low risk of developing severe mitral regurgitation, with effective mitral valve enlargement, and with sustained midterm symptomatic benefits. © 1996 Wiley-Liss, Inc.     

Successful balloon valvuloplasty for neonatal critical aortic stenosis

Transluminal balloon aortic valvuloplasty was performed in two term neonates, ages 6 and 7 days, with critical aortic stenosis. Transluminal balloon coarctation angioplasty was also performed in the second neonate. The neonates presented in congestive heart failure and underwent unsuccessful treatment with digoxin, furosemide, and careful fluid management before balloon dilatation. In the first patient, the gradient across the aortic valve was reduced from 75 mm Hg before balloon aortic valvuloplasty to 34 mm Hg after the procedure. The second neonate showed clinical improvement after both dilatation procedures. In both patients, follow-up clinical and Doppler echocardiography findings suggest persistent improvement 5 months after the procedure.