The resurgence of stand-alone balloon aortic valvuloplasty: a single centre experience

Introduction Calcific aortic stenosis is the most common manifestation of valvular disease in the western world. Operative aortic valve replacement has been the mainstay of treatment, but as the population ages the number of patients being turned down for surgery has increased. Less invasive means of tackling this pathology have therefore been sought, notably transcatheter aortic valve implantation. Whereas early results of this technology have been encouraging, it is not widely available and vascular access issues may preclude this approach altogether. Balloon aortic valvuloplasty (BAV) has previously fallen out of favour primarily because of high restenosis rates at 6 and 12 months. Procedural and technological advances are such that BAV still has a role in elderly high-risk patients seeking symptomatic improvement that is not available from medical therapy alone. Methods We report our experience spanning a 4-year period, with the data extracted from a cardiac procedures database. The procedures were performed in a cardiac catheter laboratory with onsite cardiothoracic cover. Both retrograde and antegrade approaches were utilised and the majority of procedures were pace assisted. Either Z-Med or BALT Cristal balloons were introduced via femoral arterial (or venous) sheaths ranging from 9F to 14F. All procedures were performed by two experienced operators. Results Between February 2004 and November 2008 30 cases were performed. Follow-up data were obtained from all cases. One procedure was abandoned due to very poor peripheral arterial access. The average age was 80.0 years (range 66–92). 16 were women (53%). 19 (63%) were NYHA class IV and the remainder were class III. The average echo gradient was 81 mm Hg (range 45–200), whereas the average pullback gradient was 69 mm Hg (range 30–130). The majority (28) of procedures was performed via the retrograde route. 27 (90%) procedures were pace assisted. The average gradient postprocedure was 27 mm Hg (range 0–70). Mean procedural time was 75.5 minutess with a mean fluoroscopy time of 11.2 minutes. There were three major complications within 24 h of the procedure (one myocardial infarction, one cerebrovascular accident and one death). In total there were 13 deaths. Of this group the average length of survival was 117 days, with seven deaths occurring within 30 days. 17 (57%) of the cohort are still alive, with an average survival of 317 days to date. Conclusions At a time when increasing numbers of patients with severe symptomatic aortic stenosis are presenting later in life, alternatives to surgical aortic valve replacement will need to come to the fore in view of the complex co-morbidities that are associated with this group. Our experience of BAV suggests that this procedure can be performed successfully and safely. Transcatheter aortic valve implantation is not currently widely utilised and we believe that stand-alone BAV has a significant role in improving the outcomes of these patients who have historically proved very difficult to manage.