Pre-dilation and Post-dilation in Transcatheter Aortic Valve Replacement: Indications, Benefits and Risks

Abstract

Transcatheter aortic valve replacement (TAVR) is an established treatment for patients with symptomatic severe aortic stenosis. In recent years, an emphasis has been placed on simplification of the procedure. Balloon predilation was initially considered a mandatory step to cross and prepare the stenotic aortic valve, but several studies demonstrated the feasibility of performing TAVR without balloon valvuloplasty. Balloon postdilation of the implanted valve is sometimes required to optimise results, although many patients do not require this step. Contemporary consensus advocates an individualised approach to TAVR procedures and so balloon pre- and post-dilation are performed selectively. This review aims to outline the advantages and disadvantages of balloon pre- and post-dilation and to identify the scenarios in which they are required during TAVR procedures.

Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery

“…65 66 However, postdilation has advantages, such as reduction of PVR, optimized frame expansion, and optimized valvular gradient, and disadvantages, such as risk of valve embolization, conduction disorders, leaflet damage, cerebrovascular embolism, and annular rupture. 57 67 If postdilation is no option and transvalvular or PVR remains ≥ II degrees, an additional THV prosthesis can be implanted as valve-in-valve procedure ( Fig. 3 ).…”

Intraprocedural delayed reassessment of paravalvular regurgitation in TAVR significantly reduces the use of postdilatation

“…[5][6][7][8][9] BPD improves valve expansion, but there is a trade-off with the increased risk of stroke, valve embolization or leaflet damage, conduction disorders, and annular rupture. [10][11][12][13][14] After implantation of a valve prosthesis, an elastic recoil effect of the aortic annulus is expected to take some time, as we have historically observed with coronary balloon angioplasty in coronary stenosis, particularly at the ostial level, which shares histologic features with the aorta. On the other hand, the settlement of the skirt over the annulus with changes in its thickness and texture induced by the new environment may also require some time, including thrombus deposition layering.…”

“…Despite technological advances in TAVR prostheses, BPD remains a frequently performed adjunctive procedure, 10%–20% with balloon‐expandable and 20%–40% with self‐expandable valves 5–9 . BPD improves valve expansion, but there is a trade‐off with the increased risk of stroke, valve embolization or leaflet damage, conduction disorders, and annular rupture 10–14 …”

Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study

“…Although TAVI is less invasive, heart valve interventions in elderly and often frail patients represent a challenge for perioperative anesthetic management. During the TAVI procedure, balloon valvuloplasty, the implantation of a balloon-expandable valve and post-dilatation are performed during functional circulatory arrest induced by rapid ventricular pacing (RVP) [ 13 ]. The obstruction of the left ventricular outflow tract during valvuloplasty, followed by severe aortic regurgitation, can also lead to hemodynamic deterioration through sudden left ventricular volume overload.…”