Percutaneous balloon aortic valvuloplasty revisited: time for a renaissance?

Case Presentation: A 92-yearold woman presented with progressive heart failure in the setting of known aortic valve stenosis. Despite aggressive medical therapy, she remained in New York Heart Association functional class IV. She lived in an assisted-care facility and wanted to engage in more vigorous daily activities. She did not wish to undergo surgical aortic valve replacement. An echocardiogram showed a left ventricular ejection fraction of 50%. The aortic valve was heavily calcified and severely stenotic, with a mean gradient of 64 mm Hg and an aortic valve area of 0.46 cm. The patient was offered balloon aortic valvuloplasty, to which she and her family consented. A retrograde approach with a 23-mm balloon was used. A total of 3 inflations were carried out across the aortic valve during simultaneous rapid ventricular pacing at 220 bpm. The postvalvuloplasty mean gradient was reduced to 28 mm Hg, and the aortic valve area increased to 0.98 cm. She was seen in the clinic 6 months later with stable functional class II symptoms and remained quite satisfied with her improved lifestyle. Calcific aortic stenosis (AS) is the most frequent expression of valvular heart disease in the Western world, with increasing prevalence expected as the population ages. Three percent of all adults 75 years of age have moderate or severe AS, and it is the leading indication for valve replacement in Europe and the United States. Surgical aortic valve replacement is the preferred treatment strategy for patients of all age groups, although it has limitations in the octogenarian and nonagenarian populations. Open heart approaches are limited by higher perioperative risk, prolonged recovery, and poor quality of life after surgery.1 The surgical 30-day mortality rate for the nonagenarian population is 17% in 1 contemporary series, with 40% mortality by 13 months.2 Less invasive percutaneous options are needed for poor-surgical-risk patients with severe AS. Balloon aortic valvuloplasty (BAV) is currently the only approved catheter-based option for nonsurgical patients, a procedure that has been underused in those patients relegated to medical therapy alone. This procedure fell from favor secondary to perceived procedural complexity, suboptimal initial results, and high restenosis rates in the 6 to 12 months after the procedure.3 As the number of very elderly with this disease increases, especially those in whom surgical options are not available, an effective and less invasive treatment of severe AS is essential. About one third of patients with severe AS are not referred for valve replacement surgery because of the risks perceived by both patients and physicians. The use of BAV for palliation of symptoms has been undervalued in this difficult-to-treat patient group.