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

Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty

BACKGROUND

This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2).

METHODS

From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention.

RESULTS

Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012).

CONCLUSIONS

PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Clinical Outcomes of a Non-Compliant Balloon Dilatation Catheter: MOZEC™ NC Study

The present study sought to assess the clinical outcomes of the Mozec™ Non-compliant (NC) Rx PTCA balloon dilatation catheter (BDC) (Meril Life Sciences Pvt. Ltd., Vapi, India) for dilatation of coronary lesions. This was a post-marketing, single-centre, single-arm, retrospective study. In total, 57 patients who had undergone post-dilatation with the Mozec™ NC Rx PTCA balloon dilatation catheter were evaluated. The primary endpoint was procedural success defined as (i) successful delivery of the investigational device to and across the target lesion; (ii) successful inflation, deflation, and withdrawal of the investigational device; (iii) absence of vessel perforation, flow-limiting vessel dissection, increase in thrombolysis in myocardial infarction (TIMI) flow from baseline, clinically significant arrhythmia requiring medical treatment; and (iv) achievement of final TIMI flow grade 3 after percutaneous coronary intervention of the target lesion after single or multiple attempts to cross the target lesion. Procedural success was achieved in 57 (100%) patients. There were no incidences of major adverse cardiac events (MACE)/target lesion failure (TLF). Mozec™ NC Rx PTCA balloon dilatation catheter has demonstrated favourable outcomes for the dilatation of routine and complex coronary lesions in a small cohort, as evidenced by its 100% procedural success rate and absence of MACE.

Computational Analysis of Balloon Catheter Behaviour at Variable Inflation Levels

Aortic valvuloplasty is a minimally invasive procedure for the dilatation of stenotic aortic valves. Rapid ventricular pacing is an established technique for balloon stabilization during this procedure. However, low cardiac output due to the pacing is one of the inherent risks, which is also associated with several potential complications. This paper proposes a numerical modelling approach to understand the effect of different inflation levels of a valvuloplasty balloon catheter on the positional instability caused by a pulsating blood flow. An unstretched balloon catheter model was crimped into a tri-folded configuration and inflated to several levels. Ten different inflation levels were then tested, and a Fluid-Structure Interaction model was built to solve interactions between the balloon and the blood flow modelled in an idealised aortic arch. Our computational results show that the maximum displacement of the balloon catheter increases with the inflation level, with a small step at around 50% inflation and a sharp increase after reaching 85% inflation. This work represents a substantial progress towards the use of simulations to solve the interactions between a balloon catheter and pulsating blood flow.

Use and Outcomes of Acute Treatment Strategies in Patients with Severe Aortic Valve Stenosis

Background:

This study aimed to evaluate the acute treatment of patients with severe aortic valve stenosis in Germany.

Methods and Results:

Three treatment strategies in 11,027 patients acutely admitted due to aortic valve stenosis were compared from 2014 until 2018 using German nationwide records: The annual number of transcatheter aortic valve replacement (TAVR) procedures (1,294 to 1,827) and balloon valvuloplasty (BV only) procedures (170 to 233) in patients acutely admitted increased, but surgical aortic valve replacement (SAVR) procedures decreased (426 to 316). In comparison to BV only patients (mean age 81.3; EuroSCORE 23.2) SAVR patients were younger and at lower logistic EuroSCORE (mean age 66.9; EuroSCORE 9.4). Patients treated with TAVR were at comparable age and operative risk (mean age 81.3; EuroSCORE 24.4) as those patients treated with BV only. Primary outcome was in-hospital mortality. Reimbursement was considered secondary outcome. After risk adjustment using multivariable logistic and linear regression analyses, SAVR (OR 0.26 [96%CI 0.16;0.45], p < 0.001) and TAVR (OR 0.38 [0.29;0.49], p < 0.001) were associated with lower risk for mortality compared to BV only. Compared to BV only, hospitalization costs of patients undergoing SAVR were reduced by €5,578 ([95%CI €8,023; €3,133], p < 0.001). TAVR procedures were associated with higher hospitalization costs than BV only (risk-adjusted difference €4,143 [€2,330; €5,926], p < 0.001).

Conclusions:

BV only was associated with a substantially increased risk of in-hospital mortality in acute patients. We conclude that a definitive aortic valve replacement should be preferred as primary treatment in patients with severe aortic valve stenosis causing an acute admission.

The use of semi-compliant versus non-compliant balloon systems for predilatation during the implantation of self-expandable transcatheter aortic valves: Data from the VIenna CardioThOracic Aortic Valve RegistrY (VICTORY)

BACKGROUND

This study aimed to evaluate the differences in outcome arising from the use of semi-compliant (SCB) versus non-compliant balloon (NCB) systems for predilatation during self-expanding transcatheter aortic valve replacement (TAVR).

METHODS

251 TAVR procedures with the implantation of self-expanding valves after predilatation were analyzed. SCB systems were used in 166 and NCB systems in 85 patients. The primary endpoint was defined as device success, a composite endpoint comprising the absence of procedural mortality, correct valve positioning, adequate valve performance and the absence of more than a mild paravalvular leak. The secondary endpoints were chosen in accordance with the valve academic research consortium (VARC-2) endpoint definitions.

RESULTS

No significant differences were observed with regard to procedural device success between the SCB- and NCB cohort (SCB: 142 [85.5%%] vs. NCB: 77 [90.6%]; P = .257). There was a notable difference between the rates of conversion to open surgery and the postdilatation rate, both of which were higher for the NCB group (SCB: 1 [0.6%] vs. NCB: 4 [5.1%]; P = .042; SCB: 30 [18.1%] vs. NCB: 34 [40%]; P < .001). In a multivariate logistic regression analysis, the use of semi-compliant balloon systems for predilatation was associated with a lower risk for postdilatation (OR: 0.296; 95% CI: 0.149-0.588) and conversion to open surgery (OR: 0.205; 95% CI: 0.085-0.493; P = .001) but not for device success.

CONCLUSION

While the balloon compliance did not affect the procedural mortality, device success or the rate of paravalvular leakage, the use of semi-compliant balloons for predilatation during TAVR should be investigated in larger randomized trials in the light of the lower rates of postdilatation and conversion to open surgery compared to their non-compliant counterparts.

Retrograde balloon aortic valvuloplasty with the newly invented Inoue balloon for aortic stenosis accompanied by severe heart failure: A case report

Retrograde balloon aortic valvuloplasty using the newly invented Inoue balloon was one of the feasible and safe therapeutic options in a hemodynamically unstable patient having aortic stenosis with reduced left ventricular ejection fraction complicated with bacterial infection.

Balloon aortic valvuloplasty through the novel transradial technique

BACKGROUND

Balloon aortic valvuloplasty (BAV) has been typically performed through a femoral approach thus increasing the risk of bleeding and access site-related vascular complications. The aim of this study was to describe the safety and efficacy of transradial aortic valve valvuloplasty (TRBAV).

METHODS

The present research is a retrospective, single-center study including patients undergoing TRBAV (October 2019-July 2020). BAV was performed using 18-25 mm balloons through an 8-10 French (F) radial sheath. Successful BAV was defined as ≥50% reduction in peak-to-peak gradient (efficacy endpoint). Procedural complications, including radial artery occlusion (RAO) at follow-up were evaluated (safety endpoint).

RESULTS

Twenty-four patients underwent TRBAV were included, aged 81 (73-85) years, 70% males, EuroScoreII 3.1 (2.1-5.5). Aortic valve gradient was significantly reduced (pre-50±24 vs. 18.7±13 mmHg post, P<0.001), and 91% had successful BAV. Mean gradient drop was 31.4±16.8 mmHg. One patient (4%) required cross-over to femoral access for severe vasospasm and was excluded from the analysis. Most used sheaths were 8F (46%) and 9F (37%), mostly for 20 mm (50%) and 23 mm (38%) balloons. There were neither major procedural complications (neither balloon entrapment nor compartmental syndrome) nor minor complications (any access-site bleeding). RAO was observed in 2 patients (8%), both asymptomatic.

CONCLUSIONS

TRBAV was safe, feasible, and efficacious with a small rate of conversion and RAO, suggesting reproducibility of this novel technique. TRBAV may represent an alternative to femoral access in selected patients although larger studies are warranted.

Contemporary use of balloon aortic valvuloplasty and evaluation of its success in different hemodynamic entities of severe aortic valve stenosis

OBJECTIVES

To evaluate outcome assessment of percutaneous balloon aortic valvuloplasty (BAV) in different flow and gradient patterns of severe aortic stenosis (AS).

BACKGROUND

The mean pressure gradient reduction after BAV is an often-used surrogate parameter to evaluate procedural success. The definition of a successful BAV has not been evaluated in different subgroups of severe AS, which were introduced in the latest guidelines on the management of patients with valvular heart disease.

METHODS

In this observational study, consecutive patients from July 2009 to March 2018 undergoing BAV were divided into normal-flow high-gradient (NFHG), low-flow low-gradient (LFLG), and paradoxical low-flow low-gradient (pLFLG) AS. Baseline characteristics, hemodynamic, and clinical information were collected and compared.

RESULTS

One-hundred-fifty-six patients were grouped into NFHG (n = 68, 43.5%), LFLG (n = 68, 43.5%), and pLFLG (n = 20, 12.8%) AS. Mean age of the study population was 81 years. Cardiogenic shock or refractory heart failure (46.8%) was the most common underlying reasons for BAV. Spearman correlation revealed that the mean pressure gradient reduction, determined by echocardiography, had a moderate correlation with the increase in the aortic valve area (AVA) in patients with NFHG AS (ρ: 0.529, p < .001) but showed no association in patients with LFLG (ρ: 0.017, p = .289) and pLFLG (ρ: 0.030, p = .889) AS. BAV as bridge to surgical or transcatheter aortic valve replacement was possible in 44.2% of patients, with no difference between groups (p = .070).

CONCLUSION

The mean pressure gradient reduction might be an adequate surrogate parameter for BAV success in patients with NFHG AS but is not suitable for patients with other hemodynamic entities.

Clinical outcomes following balloon aortic valvuloplasty

Background

Balloon aortic valvuloplasty (BAV) remains a treatment option for the selected patients with severe aortic stenosis. We examined clinical outcomes and predictors of prognosis in patients undergoing BAV for severe aortic stenosis.

Methods

We identified all patients undergoing BAV from January 2010 to March 2018 (n=167) at a single transcatheter aortic valve implantation (TAVI) centre. Patient demographics, investigations, subsequent interventions and clinical outcomes were obtained from electronic health records.

Results

Patients undergoing BAV were elderly (median age 80, IQR 73–86 years) and half (n=87, 52%) were male. All-cause mortality at 30 days and 12 months was 11% and 43%, respectively. Reduce ejection fraction (EF 30%–50%: HR 1.76, 95% CI 1.05 to 2.94; EF <30%: HR 1.90, 95% CI 1.12 to 3.20) was the only independent predictor at baseline of overall mortality. Median survival was 212 (IQR 54–490) days from the index procedure. Mortality at 1 year was lowest in patients who subsequently underwent TAVI or SAVR but high among those who had no further interventions or those who had a repeat BAV (14%, 19%, 60%, 89% respectively, log-rank p<0.001).

Conclusion

BAV as a bridge to definitive aortic valve intervention in carefully selected patients offers acceptable outcomes. These contemporary observational findings demonstrate the ongoing potential utility of BAV in the TAVI era.

Ultrasound-Guided Percutaneous Balloon Aortic Valvuloplasty for Aortic Stenosis

Percutaneous balloon aortic valvuloplasty (PBAV), which is used to treat symptomatic aortic stenosis, requires ionizing radiation and contrast agent for imaging guidance. The aim of the study is to evaluate the feasibility and effectiveness of ultrasound-guided PBAV in patients with aortic stenosis. This case series included 30 patients (14 males; mean age, 61.5 ± 4.5 years) with moderate/severe aortic stenosis treated with ultrasound-guided PBAV at the Ultrasound Department, Fuwai Hospital, Beijing, China, between January 2016 and July 2019. Cardiac function (New York Heart Association grade) was assessed before PBAV and 1 month after the procedure. Aortic peak jet velocity, aortic valve orifice area (AVA), mean transvalvular pressure gradient (MTPG), left ventricular end-diastolic diameter (LVDD), left ventricular ejection fraction (LVEF), and left ventricular end-systolic diameter (LVESD) were determined before and immediately after PBAV using Doppler echocardiography. Preprocedural cardiac function was grade I in 3 cases, grade II in 9 cases, grade III in 10 cases, and grade IV in 8 cases. Postprocedural cardiac function was grade I in 22 cases, grade II in 4 cases, and grade III in 4 cases, suggesting that cardiac function was improved by PBAV. Ultrasound-guided PBAV resulted in significant improvements (P < 0.05) in aortic peak jet velocity (3.68 ± 0.811 m/s vs. 4.79 ± 0.63 m/s), MTPG (33.77 ± 13.85 mmHg vs. 54.54 ± 13.81 mmHg), AVA (1.96 ± 0.25 cm² vs. 0.98 ± 0.12 cm²), LVEDD (51.90 ± 3.21 mm vs. 65.60 ± 6.81 mm), LVEF (63.46 ± 11.29% vs. 56.31 ± 11.04%), and LVESD (35.50 2.62 mm vs. 45.20 ± 2.42 mm). Ultrasound-guided PBAV is feasible and achieves good short-term effects in patients with aortic stenosis.

Evaluation of the NuCLEUS-X™ balloon valvuloplasty catheter for severe pulmonic stenosis in dogs

INTRODUCTION/OBJECTIVES

Balloon instability is commonly encountered during balloon pulmonary valvuloplasty (BPV) and may result in an unsuccessful procedure. The NuCLEUS-X™ catheter is a recently developed BPV catheter with a unique barbell shape and an ordered pattern of inflation that stabilizes the balloon to span the valve annulus before expansion of the balloon center.

ANIMALS

Ten client-owned dogs with severe valvular pulmonic stenosis (PS).

MATERIALS AND METHODS

Prospective observational study. The BPV procedure was performed by standard technique with use of NuCLEUS-X™ catheters targeting a balloon-to-annulus ratio between 1.2 and 1.5. Balloon stability, safety, and procedural success were assessed. Procedural success was defined as either a reduction in the Doppler transpulmonic PG by at least 50% of the pre-procedural PG or <80 mmHg one month post procedure.

RESULTS

Balloon stability centered at the pulmonic valve on the first inflation was achieved in 10/10 cases. The mean PG before BPV was 141 mmHg ±41 mmHg, and the PG after BPV at one month was 83 mmHg ±41 mmHg. Procedural success was achieved in 56% of patients. All dogs survived the BPV, and no major procedural complications were encountered using the NuCLEUS-X™ catheter.

CONCLUSIONS

The use of the NuCLEUS-X™ catheter is feasible for BPV in dogs with severe PS. The unique balloon shape provided catheter stability on the first inflation in all dogs, which may be beneficial when stabilization of a conventional BPV catheter cannot be achieved.

Balloon Aortic Valvuloplasty Using a Non-Occlusive Balloon Catheter: First Animal Experience

BACKGROUND

Transcatheter aortic valve implants (TAVI) have revolutionised the treatment of elderly patients requiring aortic valve replacement. These patients often do not tolerate balloon valvuloplasty well, and a valvuloplasty balloon that would allow a degree of continued cardiac output during expansion would be beneficial. We tested such a balloon and describe our results in the sheep model.

METHODS AND RESULTS

We developed a non-occlusive balloon (NOB) catheter. An acute experiment was performed where the NOB was inflated in six sheep in the aortic valve position without any attempt to arrest cardiac output. Two inflations were performed per animal: the first for 30 s and the second for 2-3 min. Standard occlusive balloons were inflated in two animals under rapid ventricular pacing to serve as controls. Mean pressure gradient across the NOB was 9.7 ± 5 mmHg during the inflations and all animals remained hemodynamically stable during NOB inflations.

CONCLUSIONS

The novel non-occlusive balloon catheter, which permitted uninterrupted cardiac output for a prolonged period without the need for pacing-induced temporary cessation of cardiac output, is both feasible and well tolerated in the acute sheep model.

Using the Arm for Structural Interventions: Case Selection or Wave of the Future

The transradial approach has emerged as the preferred alternative to the traditional transfemoral approach owing to the increased evidence of its safety and efficacy. The field of structural heart disease is rapidly evolving; however, periprocedural complications related to access site remain a major determinant of morbidity and mortality. The transradial approach as primary or secondary access site in structural heart interventions like transcatheter aortic valve replacement, balloon aortic valvuloplasty, alternative access, alcohol septal ablations, paravalvular leak, valve snaring, coronary protection, and ventricular septal defect is feasible, safe, with lower vascular complications and high procedural success.

Balloon Aortic Valvuloplasty in Patients Admitted for Cardiogenic Shock with Severe Aortic Stenosis: A Retrospective Analysis of 14 Cases

Introduction Balloon aortic valvuloplasty (BAV), introduced in 1986, quickly lost its wide adoption due to the high incidence of restenosis after the procedure and due to improved skills in transcatheter aortic valve implantation (TAVI). It has seen a re-emergence in the last few years as bailout therapy in critical care patients presenting with cardiogenic shock (CS) and severe aortic stenosis (AS), who are temporarily unable to tolerate such a procedure as TAVI or surgery for valve replacement. Methods We did a retrospective analysis of every BAV performed between January 1, 2008, and November 11, 2018, in our hospital and identified those admitted to the cardiac intensive care unit (CICU) due to cardiogenic shock with severe aortic stenosis, as defined in the European Society of Cardiology Guidelines. Procedures were categorized as emergent (within 24h after the decision to intervene) and urgent (24h after the decision was made but before discharge). Results During this period, of 98 BAV performed, 14 were performed on patients with CS with severe AS, nine of them being emergent. The patients' mean age was 76.2±7.2 years, with 6 (43%) of them being female. On the day of BAV, the mean Euroscore II and sequential organ failure (SOFA) were, respectively, 19±7% and 8.0±2.4 in emergent cases and 11±5% and 4.8±2.9 in urgent cases. In patients deemed emergent, there was a tendency for a decrease in SOFA in the days following the procedure, although not statistically significant (p>0.05). Clinically significant aortic regurgitation did not occur in any patient, neither were there any major post-procedure complications. Thirty-day mortality was 33% in emergent cases and 0% in urgent cases. In emergent cases, four were later submitted to TAVI and one had surgery for aortic valve replacement surgery. Only one patient in the urgent group was regarded as a candidate for TAVI. Discussion and conclusion Emergent cases presented with higher scores of severity and procedure risk and had greater mortality. In this group, a greater proportion of survivors was later deemed fit for definite procedures. This highlights that presenting status does not seem to influence the prognosis of those extremely high-risk patients once the acute event is promptly treated. Nevertheless, the low sample size precludes generalization of the findings. BAV as bailout treatment may be safe in patients presenting with CS and severe AS, allowing patient survival for elective definitive treatment.

Balloon aortic valvuloplasty via a bilateral trans-radial artery approach prior to transcatheter aortic valve replacement

Balloon aortic valvuloplasty (BAV) intervention is used as destination therapy or as a bridge to percutaneous or surgical aortic valve intervention. BAV is traditionally performed via a transfemoral approach; however, this may not be feasible in all patients due to peripheral vascular disease. We present a case of BAV performed via bilateral transradial access utilizing simultaneous deployment of two angioplasty balloons.