Randomized comparison of balloon aortic valvuloplasty performed with or without rapid cardiac pacing: The pacing versus no pacing (PNP) study

Balloon aortic valvuloplasty in neonates: short- and long-term effects and predictors of successful outcome

Introduction

Balloon aortic valvuloplasty (BAV) is a common treatment method of aortic valve (AV) stenosis in neonates. Long-term BAV effects are suboptimal, and their predictors are not well acknowledged.

Aim

To identify predictors of suboptimal short- and long-term BAV results.

Material and methods

The study group comprised forty-three neonates (8 females; weight 3.34 ±0.56 kg) who underwent BAV between 1998 and 2021. Seventeen patients (39.53%) had critical AV stenosis. AV was bicuspid in 22 patients, tricuspid in 12, unicuspid in 2, and undefined in 7 patients. The mean balloon/annulus ratio was 0.9 ±0.07. Catheterization, clinical, and follow-up data were analysed.

Results

The peak-to-peak gradient decreased from 67.5 ±26.3 to 21.3 ±12.6 mm Hg. Twenty-eight patients (65.1%) had adequate early outcome. Aortic regurgitation (AR) occurred in 13 (30.2%) patients. No predictors of inadequate early outcome were found. Twenty-year survival was 90.7%. Eleven (35.5%) patients underwent reintervention at a median of 12 (1–215) months; BAV in 5 patients, surgical valvuloplasty in 2, Ross operation in 2, AV replacement in 1, and Norwood operation in 1 patient. Fifteen-year freedom from reintervention (FFR) was 48%. Adequate early outcome resulted in higher FFR (71% vs. 22%), and so did no significant AR (60% vs. 30%).

Conclusions

BAV provides satisfying early results. AR remains a significant aftermath of BAV. Risk factors and procedural techniques improving the outcome of BAV are unclear. Further research is needed to improve FFR.

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.

Direct Rapid Left Ventricular Wire Pacing during Balloon Aortic Valvuloplasty

Background: Rapid ventricular pacing is mandatory for optimal balloon positioning during aortic valvuloplasty (BAV) in patients with severe aortic stenosis. We aimed to assess the safety and efficacy of direct left ventricular (LV) guidewire pacing in comparison with regular pacing induced by temporary pacemaker (PM) placement in the right ventricle. Methods: Direct rapid LV pacing was provided with a 0.035″ guidewire. Baseline clinical characteristics, echocardiographic and procedural data, as well as complication rates, were compared between the two groups. Results: A total of 202 patients undergoing BAV were enrolled (49.5% with direct LV guidewire pacing). The pacing success rate was 100%. In the direct LV guidewire pacing group, we found a lower radiation dose, shorter fluoroscopy and overall procedural time (0.16 vs. 0.28 Gy, p = 0.02; 5.4 vs. 10.3 min, p = 0.01; 17 vs. 25 min, p = 0.01; respectively). In addition, the complication rate was lower in that group (cardiac tamponades, vascular access site complications, blood transfusions rate, and in-hospital mortality: 0% vs. 3.9%; 4.0% vs. 15.7%; 2.0% vs. 12.7%; 2.0% vs. 9.8%, p = 0.01 for all, respectively). Conclusions: Direct rapid LV guidewire pacing is a simple, safe and effective option for BAV with a reduced complication rate compared to a temporary PM placed in the right ventricle.

Contemporary balloon aortic valvuloplasty: Changing indications and refined technique

Even if un to improve long-term prognosis, balloon aortic valvuloplasty (BAV) may be useful in selected patients with symptomatic severe aortic stenosis either as a bridge to surgical or transcatheter valve replacement (aortic valve replacement [AVR] or transcatheter aortic valve implantation [TAVI]) or as a triage strategy for patients with uncertain indications. International guidelines recommend BAV as: a "bridge" to AVR/TAVI, a "trial" in patients with undetermined symptoms, or a "bridge-to-decision" in case of comorbidities. However, in clinical practice, BAV is also used as a palliative measure to improve hemodynamics and quality of life in many patients who are excluded from AVR/TAVI. Finally, BAV is often performed during TAVI to facilitate prosthesis delivery, optimize frame expansion, or for bioprosthetic valve fracture in selected valve-in-valve procedures. Technical innovations, which allow for a mini-invasive approach via transradial access and pacing delivered through the wire, have led to a decrease in complications over time. This review focuses on contemporary BAV with a specific emphasis on new indications, innovative techniques, and specific complex patient subgroups.