Balloon Aortic Valvuloplasty as a Bridge to Aortic Valve Replacement

Balloon aortic valvuloplasty bridge to transcatheter aortic valve replacement is associated with worse in-hospital mortality

BACKGROUND

Balloon aortic valvuloplasty (BAV) has gained renewed interest as a bridge to transcatheter aortic valve replacement (TAVR) for patients with aortic stenosis (AS). However, it is unclear whether they patients should undergo TAVR directly or receive a staged bridge to BAV before TAVR is unclear. We used a national database to examine the association between BAV and TAVR in patients with TAVR and its effect on in-hospital mortality.

METHODS

Using the nationwide inpatient database of the Japanese registry of all cardiac and vascular diseases and the combination of the diagnosis procedure combination, we retrospectively analyzed 27,600 patients with AS who underwent TAVR between October 2013 and March 2021. Outcomes of the direct TAVR group (n = 27,387) were compared with those of the BAV bridge to TAVR group (n = 213), which received BAV at least 1 day before TAVR.

RESULTS

The median age was 85 (interquartile range: 82-88) years, with 33.3% (n = 9188) being male. Unplanned/emergent admissions increased with TAVR, whereas the use of BAV bridge to TAVR decreased. The in-hospital mortality rate was 1.3% and decreased over time. However, the BAV bridge to TAVR had a significantly higher in-hospital mortality than direct TAVR (5.6% vs. 1.3%; p < .0001). Factors associated with in-hospital mortality included age, body mass index, chronic renal disease, percutaneous coronary intervention, and BAV bridge to TAVR.

CONCLUSIONS

In unplanned/emergent and planned admission settings, the in-hospital mortality rate for BAV bridge to TAVR is worse than that for direct TAVR. Practical criteria for BAV bridge to TAVR should be proposed to improve outcomes.

Acute Heart Valve Emergencies

Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.

Acute advanced aortic stenosis

Acute decompensation often represents the onset of symptoms associated with severe degenerative aortic stenosis (AS) and usually complicates the clinical course of the disease with a dismal impact on survival and quality of life. Several factors may derange the faint balance between left ventricular preload and afterload and precipitate the occurrence of symptoms and signs of acute heart failure (HF). A standardized approach for the management of this condition is currently lacking. Medical therapy finds very limited application in this setting, as drugs usually indicated for the control of acute HF might worsen hemodynamics in the presence of AS. Urgent aortic valve replacement is usually performed by transcatheter than surgical approach whereas, over the last decades, percutaneous balloon valvuloplasty gained renewed space as bridge to definitive therapy. This review focuses on the pathophysiological aspects of acute advanced AS and summarizes current evidence on its management.

Development and Validation of a Machine Learning Score for Readmissions After Transcatheter Aortic Valve Implantation

Background

Identifying predictors of readmissions after transcatheter aortic valve implantation (TAVI) is an important unmet need.

Objectives

We sought to explore the role of machine learning (ML) in predicting readmissions after TAVI.

Methods

We included patients who underwent TAVI between 2016 and 2019 in the Nationwide Readmission Database. A total of 917 candidate predictors representing all International Classification of Diseases, Tenth Revision, diagnosis and procedure codes were included. First, we used lasso regression to remove noninformative variables and rank informative ones. Next, we used an unsupervised ML model (K-means) to identify patterns/clusters in the data. Furthermore, we used Light Gradient Boosting Machine and Shapley Additive exPlanations to specify the impact of individual predictors. Finally, we built a parsimonious model to predict 30-day readmission.

Results

A total of 117,398 and 93,800 index TAVI hospitalizations were included in the 30- and 90-day analyses, respectively. Lasso regression identified 138 and 199 informative predictors for the 30- and 90-day readmission, respectively. Next, K-means recognized 2 distinct clusters: low risk and high risk. In the 30-day cohort, the readmission rate was 10.1% in the low risk group and 23.3% in the high risk group. In the 90-day cohort, the rates were 17.4% and 35.3%, respectively. The top predictors were the length of stay, frailty score, total discharge diagnoses, acute kidney injury, and Elixhauser score. These predictors were incorporated into a risk score (TAVI readmission score), which exhibited good performance in an external validation cohort (area under the curve 0.74 [0.7-0.78]).

Conclusions

ML methods can leverage widely available administrative databases to identify patients at risk for readmission after TAVI, which could inform and improve post-TAVI care.

Balloon aortic valvuloplasty: current status and future prospects

INTRODUCTION

Balloon aortic valvuloplasty (BAV) improves hemodynamic and clinical status of patients with severe aortic stenosis (AS) for a limited period of 6-12 months. However, there is a high number of procedures performed worldwide and an upward trend over the last decades.

AREAS COVERED

Epidemiology of AS and the advent of transcatheter aortic valve implantation (TAVI) contribute to the extensive referral of patients. The expansion of recommendations for TAVI has occasionally led to financial reimbursement-related problems that do not exist for BAV. BAV is indicated as a bridge to valve replacement, to decision in complex cases, and to extracardiac surgery. BAV may play a role in preparing for TAVI and optimizing procedural results. The minimalist approach and reduced complication rate make it applicable in fragile patients.

EXPERT OPINION

In the near future, BAV will continue to be a useful asset in managing patients with AS given the multiple indications, broad applicability, safety profile, low cost, and repeatability. Specific studies are necessary to explore technical solutions, stronger indications, the finest technique, and to standardize the procedural result. Pending the development of potential competitive devices, the role that BAV plays will remain closely intertwined with the one played by TAVI.

Balloon aortic valvuloplasty review: the revenge during COVID-19 outbreak?

Aortic stenosis is a highly prevalent cardiac valvular disease in adult population and increases with age. After symptoms onset in severe aortic stenosis, the prognosis begins to decline; however, new studies demonstrate an increased risk of death in patients with moderate disease. Although majority of patients with severe aortic stenosis are treated electively with surgical or transcatheter aortic valve replacement, not all patients are candidates for the interventions. Balloon aortic valvuloplasty can be used successfully as a bridge to definitive treatment or as palliative therapy in patients who are not candidates for either procedure. In this paper, we discuss and justify the current indications and contraindications for balloon aortic valvuloplasty. Additionally, the step-by-step procedure technique and most frequent complications are described. Moreover, we present the safety and feasibility of balloon aortic valvuloplasty in 33 consecutive patients on a waiting list for transcatheter aortic valve replacement at 3 expert Italian centers during the first and second waves of COVID-19, when clinical priorities focused on hospitalized patients with pneumonia. The procedural success in this cohort of patients was achieved in 31 patients (94%). Out of the 33 patients enrolled, 15 underwent TAVR within 5 ± 2 months from the valvuloplasty, and at 6-month follow-up a total of 2 patients died for end-stage heart failure.

Safety, efficacy and impact on frailty of mini-invasive radial balloon aortic valvuloplasty

OBJECTIVE

The study was designed to: (1) confirm safety and feasibility of mini-invasive radial balloon aortic valvuloplasty (BAV); (2) assess its impact in terms of quality of life and frailty; and (3) evaluate whether changes in frailty after BAV are associated with death in patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

330 patients undergoing BAV in 16 Italian centres were prospectively included. The primary endpoint was the occurrence of major and minor Valve Academic Research Consortium (VARC)-2 bleeding. Secondary endpoints were scales of quality of life, frailty, evaluated at baseline and 30 days, and their relationship with the occurrence of all-cause death.

RESULTS

BAV was performed by radial access in 314 (95%) patients. No VARC-2 major and six (1.8%) VARC-2 minor bleedings occurred in the study population. Quality of life, as well as frailty status, significantly improved 30 days after BAV. At 1 year, patients undergoing TAVI with baseline essential frailty toolset (EFT) <3 or achieving an EFT <3 after BAV had a comparable occurrence of all-cause death (15% vs 19%, p=0.58). On the contrary, patients with EFT ≥3 at 30 days despite BAV showed the worst prognosis (all-cause death: 40% vs 15% and 19%, p=0.006 and p=0.05, respectively).

CONCLUSIONS

Mini-invasive radial BAV is safe, feasible and associated with a low rate of vascular complications. Patients improving EFT 30 days after BAV showed a favourable outcome after TAVI.

TRIAL REGISTRATION NUMBER

NCT03087552.