Balloon Aortic Valvuloplasty

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Peter C. Block M.D. Andreas Gruentzig
Cardiovascular Center Emory University
Balloon Aortic Valvuloplasty
AATS Sept. 2005
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When it is considered how narrow the opening is,
which these constrictions leave, it is difficult
to conceive how such an organic derangement can
continue for years. It is evident, if such an
obstacle to the circulation were suddenly
introduced into a healthy subject, death
would immediately follow but as these obstacles
are slowly formed, the circulation is gradually
impeded and nature seems in some measure to be
habituated to such a perversion of her laws.
J. N. Corvisart
1803
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ACC GuidelinesAortic Stenosis

• In the vast majority of adults, AVR is the only
  effective treatment for severe AS. Although
  there is some lack of agreement about optimal
  timing of surgery, particularly in asymptomatic
  patients.
• Bonow et al. ACC/AHA task Force Report

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Balloon ValvuloplastyThe History

• 1950s Intraoperative dilatation for valve
  conservation
• 1982 Pulmonary Valve in Children
• - Kan
• - Pepine
• 1983 Hypoplastic PV and PAs Lock
• Coarctation Lock
• 1984 Aortic stenosis in Children Lababidi
• 1983 Mitral stenosis Inoue
• 1985 Acquired Aortic stenosis in 3 pts Cribier
• 1987 Aortic stenosis in Children - Choy
• 1987 Cribier - 92pts and Block - 55pts
• 1986 Mansfield Registry
• 1987 NHLBI Registry

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• What is the role of Balloon Aortic Valvuloplasty
  in 2005?

• Neonatal, childhood and adolescent applications
  are well established.
• 2) Fetal application remains experimental.
• 3) The rare adult with AS

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Aortic Valve ReplacementNew York State 2002

• 77,075 Heart Operations
• 19,057 Valve operations
• 4943 Isolated Aortic Valve Replacements
• Mortality 3.54
• 4704 Aortic Valve Replacement with CABG
• Mortality 6.27

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Aortic StenosisSurvival without Intervention
Ross J. Circ 1968 37, Suppl V
Carabello, B. A. N Engl J Med 2002346677-682
OKeefe et el. 1987.
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So what about valvuloplasty?
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Balloon Aortic ValvuloplastyMajor Series

• Mansfield Scientific Registry, n 492
• NHLBI Registry, n 674
• Cribier (French Registry), n 406
• Block , n 375
• Safian , n 170
• Lieberman , n 165
• Lewin , n 125
• Ferguson , n 73

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Balloon Aortic ValvuloplastyAcute
OutcomeSuccess ?
In absence of data correlating final AVA to
clinical response, and in the difficulty in
estimating AVA Any definition of success is
arbitary
- Bashore et al

• Mansfield Registry
• 87 Success - i.e. alive, no AVR, a significant
  ? AVA
• NHLBI
• 95
• Kuntz et al
• 93

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Balloon Aortic ValvuloplastyHemodynamic results
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Balloon Aortic ValvuloplastyAcute Hemodynamic
Results
674 pts in NHLBI Registry
Circ 1991842383-2397
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Balloon Aortic ValvuloplastyAcute Hemodynamic
ResultsValve Area

• AVA increased 0.5 0.2 to 0.8 0.3 cm2
• Range 0.1 1.4 to 0.1
  3.4 cm2
• 77 ? AVA lt 0.4 cm2
• 13 ? AVA 0 cm2
• AVAF 1cm2 in only 29
• Start with AS and end with AS

NHLBI. n 674
Circ 1991842383-2397
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Balloon Aortic ValvuloplastyEffect of Procedural
variables
..the optimal technique . . . . not yet defined
n 492 ? lt or gt 20mm
? lt or gt 30 sec
McKay 1991 JACC
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Balloon Aortic Valvuloplasty30 Day Functional
Status
NYHA Functional Class (364 improved)
Functional Class Score (257 improved)
484 Survivors from NHLBI Registry
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Balloon Aortic ValvuloplastyHemodynamic
Follow-upMansfield Registry
Post BAV
6 month f/u
n 95
n 95
AVA Baseline - cm2
AVA Baseline - cm2
6.2 3.3 mnths
Bashore JACC 19911188
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Balloon Aortic ValvuloplastyHemodynamic Follow-up
6.2 3.3 mnths n 95
Mansfield Registry
Bashore JACC 19911188
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Balloon Aortic Valvuloplasty

• Complications -

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Balloon Aortic ValvuloplastyArteriotomy
management

• Manual, C-clamp or Femostop
• Suture closure
• Post procedure with 10F sheath
• Preclose with 6 or 8F devices
• Feldman,Michaels, Marchant
  Solomon successful closure with
  no complications

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Balloon Aortic Valvuloplasty

• Mortality -

Procedural
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Balloon Aortic ValvuloplastyPredictors of 30 day
Mortality
Variables identified in multivariate analysis
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Balloon Aortic ValvuloplastyClinical Follow-up
Mansfield Registry Data
6.2 3.3 mnths n 95
Bashore JACC 19911188
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Balloon Aortic ValvuloplastyLong Term Follow up
Months
Kuntz R NEJM 199132517
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Balloon Aortic Valvuloplasty Why such poor
outcomes ?

• The patient
• Medical Co-morbidities
• Coronary Artery Disease
• 50 of patients
• Inadequate residual valve area
• lt 1 cm2 in most patients post procedure

• The procedure
• Fracture of calcific nodules
• Commissural splitting
• Annular stretching

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Aortic Stenosis
Recommendations for Aortic Balloon Valvotomy in
Adults With Aortic Stenosis
Bonow et al. 1998 ACC/AHA Task Force
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Balloon Aortic Valvuloplasty?

• Benefits
• Yes, but transient
• Risks
• Yes
• Alternatives
• AVR
• Alters natural history but also carries risk
• Percutaneous AVR ?
• The future?
• The only role for BAV ?

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Balloon Aortic Valvuloplasty (may) will be
necessary again..
But wait

• as a preliminary to Perc. AVR

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BAV in autopsied heart. Note cracks in Ca
nodules
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X-ray of BAV in autopsied heart(note splits in
Ca nodules
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Take home messages

• BAV may hold some valuable lessons for the future
  of Rx of aortic stenosis
• BAV may still be needed to help
  rearrange/split/move Ca
• BAV may be needed to allow passage of PAVR
  devices
• In the desperately ill pt. BAV may be lifesaving
  and allow further therapeutic options

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BAV may hold some valuable lessons