Balloon aortic valvuloplasty revisited: The role of the Inoue balloon and transseptal antegrade approach

Abstract

Percutaneous aortic balloon valvuloplasty (PABV) was developed to provide a less invasive alternative to aortic valve replacement. Despite initially favorable results, PABV has not produced reliable and durable outcomes. The Inoue balloon used for PABV via an antegrade transseptal approach may offer an improvement over the Mansfield balloons via the identical route. Thirteen consecutive patients with severe symptomatic aortic stenosis were referred for percutaneous aortic balloon valvuloplasty. All patients were considered unacceptably high-risk surgical candidates. Seven consecutive patients underwent antegrade transseptal PABV with Mansfield balloons and in the following six the Inoue balloon was used. The study group was characterized by advanced age (mean, 77) and multiple comorbid conditions (mean, 2.5/patient). Before PABV, the two groups did not differ with respect to age, mean NYHA class, LVEF, transaortic gradient, cardiac output, or aortic valve area. All patients had initial hemodynamic improvement. Complications included one stroke and one vascular injury. After valvuloplasty, cardiac output was not significantly changed. However, there was a significant decrease in aortic gradient and an increase in aortic valve area in both groups; the increase in aortic valve area was significantly greater in those treated with the Inoue balloon (P = 0. 039). Total follow-up mortality was high but appeared to be delayed in the Inoue group. The use of the Inoue balloon with an antegrade transseptal approach warrants further investigation as a preferred technique for PABV.

Percutaneous Balloon Aortic Valvuloplasty Revisited

“…The Inoue balloon (typically used for mitral valvuloplasty) improves immediate post-BAV aortic valve area compared with conventional and retrograde BAV. 11 Enhanced valve opening may be achieved through leaflet hyperextension into the broader aortic root diameter. The "dumbbell"-shaped Inoue balloon locks on the aortic valve and can accomplish leaflet hyperextension with a rounded distal end without overstretching the valve annulus engaged by the narrower neck.…”

Rapid Ventricular Transvenous Pacing via Pulmonary Artery Catheter: Deliberate Hypotension Technique for Precise Proximal Thoracic Aortic Stent Graft Deployment

“…Rapid ventricular pacing allows for quickly ceasing cardiac output with fast recovery when the pacing is discontinued. This technique has been described by cardiologists for use via transfemoral venous approach in the cardiac catheterization laboratory for aortic endograft deployment [7][8][9], aortic valve balloon valvuloplasty [10] and transcatheter aortic valve replacement [11]. Nevertheless, the use of a standard pulmonary artery catheter (PAC) for rapid ventricular pacing by anesthesiologists is a practical option that has recently been described in the surgical literature [12].…”

Transseptal Antegrade Access for Aortic Valvuloplasty

“…Eisenhauer et al [1] report the results of antegrade balloon aortic valvuloplasty in 13 patients with two stated objectives, first to avoid the use of large French arterial access and the second to provide more durable results. They find technical success in all 13 patients and interestingly note that use of the Inoue balloon catheter compared to the Mansfield catheter resulted in greater valve area after dilatation.…”

“…While atrial septal defect is usually not clinically important in and of itself, it may result in small left-to-right shunts with a small but important effect on cardiac output and thus valve area calculation [2]. The conclusions noted by Eisenhauer et al [1] regarding differences in valve area after conventional versus Inoue balloon dilatation must eventually be reevaluated with either careful shunt measurements or balloon occlusion of the intra-atrial septum to eliminate the confounding effect of this phenomenon. One consideration for the conventional retrograde approach is avoiding the transseptal puncture, which may be attractive for some patients, such as those with atrial thrombus or severe kyphoscoliosis.…”

“…Eisenhauer et al [1] notes the intriguing potential advantage of the Inoue balloon catheter based on its shape for aortic valvuloplasty. The possibility that the dumbbell shape better effects dilatation of the leaflets is intriguing.…”