Balloon Aortic Valvuloplasty for Severe Aortic Stenosis as Rescue or Bridge Therapy

Abstract

The study aimed to assess procedural complications, patient flow and clinical outcomes after balloon aortic valvuloplasty (BAV) as rescue or bridge therapy, based on data from our registry. A total of 382 BAVs in 374 patients was performed. The main primary indication for BAV was a bridge for TAVI (n = 185, 49.4%). Other indications included a bridge for AVR (n = 26, 6.9%) and rescue procedure in hemodynamically unstable patients (n = 139, 37.2%). The mortality rate at 30 days, 6 and 12 months was 10.4%, 21.6%, 28.3%, respectively. In rescue patients, the death rate raised to 66.9% at 12 months. A significant improvement in symptoms was confirmed after BAV, after 30 days, 6 months, and in survivors after 1 year (p < 0.05 for all). Independent predictors of 12-month mortality were baseline STS score [HR (95% CI) 1.42 (1.34 to 2.88), p < 0.0001], baseline LVEF <20% [HR (95% CI) 1.89 (1.55–2.83), p < 0.0001] and LVEF <30% at 1 month [HR (95% CI) 1.97 (1.62–3.67), p < 0.0001] adjusted for age/gender. In everyday clinical practice in the TAVI era, there are still clinical indications to BAV a standalone procedure as a bridge to surgery, TAVI or for urgent high risk non-cardiac surgical procedures. Patients may improve clinically after BAV with LV function recovery, allowing to perform final therapy, within limited time window, for severe AS which ameliorates long-term outcomes. On the other hand, in patients for whom an isolated BAV becomes a destination therapy, prognosis is extremely poor.

Prognosis of patients with active cancer undergoing transcatheter aortic valve implantation: An insight from Japanese multicenter registry

“…TAVI could be a possible treatment option even in patients with metastasis; multidisciplinary management by oncology and cardiovascular experts is recommended for such cases. If the life expectancy is undetermined or less than 1 year, balloon aortic valvuloplasty is a viable option as a bridge to definitive therapy or a palliative procedure [24] .…”

Balloon aortic valvuloplasty for severe aortic stenosis may reduce mitral regurgitation in mid-term follow-up

“…Immediate results of BAV include an increase in AVA and a decrease in maximal and median transaortic gradient [14][15][16][17][18][19][20]. Moreover, in most patients, improvement of LVEF was crucial for better outcomes [10,13]. The data on MR reduction after BAV are limited.…”

ASに伴う院外心停止に対して，V–A ECMOでの蘇生後，急性期にBAVを行うことで良好な転帰が得られた症例(A case of out–of–hospital, AS–induced cardiac arrest, resuscitated with V–A ECMO followed by BAV in the acute phase with a good outcome)

“…症候性の重症ASに対する根本的治療はSAVRである 2)。一方で，BAVは症状のある重症ASに対する姑息的治療の1つで，大動脈弁開口部でバルーンを拡張させることで大動脈弁口面積の開大を目指す手技である。近年，重症ASに対する根本的治療の1つである経カテーテル的大動脈弁留置術（transcatheter aortic valve implantation: TAVI）の登場により，BAVはSAVRもしくはTAVIを行うまでのbridge therapyとして位置づけられるようになった 4), 5)。本症例では重症ASによりVFが頻発し，抗不整脈薬のみではその制御が不十分であったことから，さらなる介入が緊急で必要と考えられた。また大動脈弁の形態が無冠尖と右冠尖が石灰化により癒合した後天性二尖弁だった。V–A ECMO装着下でTAVIを施行したAS症例の報告は見られる 6)が，本症例は，診療の時点で大動脈弁二尖弁に対するTAVIは適応外 7)であった。手技の簡便さと侵襲度や緊急度を考慮した結果，一期的なSAVRよりBAVによるbridge therapyを行うほうが妥当と判断した。BAVを施行した後VFの再発は認めず，結果としてASの根本的治療であるSAVRの施行につなげることができた。…”