Original title: Balloon aortic valvuloplasty in the era of transcatheter aortic valve replacement: Acute and long-term outcomes. Reference: Hélène Eltchaninoff et al. Am Heart J 2014;167:235-40.
Late 80s initial enthusiasm in aortic valvuloplasty was quickly tempered with the publication of several studies showing a high rate of complications, poor durability and little or no impact on survival. Since then there have been several changes such as the reduction in the diameter of the introducer, rapid pacing, percutaneous closure devices and above all: Transcatheter Aortic-Valve Implantation (TAVI) in 2002 that make the valvuloplasty technique resurge. Patients with severe aortic stenosis (AS) and heart failure, severe impairment of ventricular function or cardiogenic shock who may be eligible for definitive therapy (percutaneous or surgical valve replacement) can receive valvuloplasty as a bridge. Other possible indication is for those patients with symptomatic AS, who must undergo urgent noncardiac surgery and less often as a compassionate method to alleviating symptoms. 323 consecutive patients who underwent aortic valvuloplasty in a center between 2005 and 2008 were included. The Crystal Balloon (BALT Extrusion, Montmorency, France) in diameters of 20, 23 and 25 mm was used in the procedure, although overall used by default was the 23. To stabilize the position through the valve, a rapid pacing (180-200 beats / min) was systematically performed.
Procedural success was defined to a valve area of ≥ 1 cm² or a decreased gradient average of > 50 %. From 323 patients, the procedure in 239 (74%), was performed as a bridge replacement, in 49 (15.2 %) by clinical instability either cardiogenic shock or refractory heart failure and in 37 ( 11.4 %) prior to noncardiac surgery. All were at high risk with a mean age of 80.5 ± 9.9 years and a mean logistic EuroSCORE of 28.7 ± 12.5 %. After valvuloplasty mean gradient decreased (from 44.0 ± 18.9 to 20.7 ± 11.0 mm Hg, P = 0.001) and increased valve area (0.68 ± 0.25 to 1.12 ± 0.39 cm2, P = 0.001) significantly. The definition of success in 261 patients (80.8 %) was achieved. 8 deaths (2.5 %) in-hospital and 22 major complications (6.8 %) were observed. Of these last, 8 (2.5 %) were related to access and 6 were strokes (1.8 %). A follow-up at 20.7 ± 20 months over 85 patients (26.3 %) was obtained, eventually, this group received definitive therapy (surgery 9.6 % and TAVI 16.7%). 238 patients (65 %) remained with medical therapy only. The estimated 5-year survival after valvuloplasty was 40% for those who eventually underwent surgery, 22 % for those who received TAVI, and 3.3 % for those received medical treatment (log -rank p < 0.001).
Conclusion:
The immediate results after aortic valve replacement are satisfactory with acceptable complication rate. Survival in monitoring for those who finally received surgery or percutaneous replacement was reasonable considering that the study was conducted at the beginning of the era of percutaneous replacement.
Editorial comment
At the time when the study was conducted, percutaneous replacement was not a standard procedure in France so to receive TAVI patients should enter to some randomized trial or registry with their corresponding inclusion and exclusion criteria. Today there were probably many more to come percutaneous replacement.
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