Challenges in the management of aortic stenosis

BALLOON AORTIC VALVULOPLASTY IS SEEING A RESURGENCE

In large part due to rising interest in managing aortic stenosis and to the anticipated diffusion of transcatheter aortic valve replacement, balloon aortic valvuloplasty has seen a resurgence in recent years.

This procedure can be considered in a number of situations. In patients with severe aortic stenosis who are hemodynamically unstable and for whom urgent aortic valve replacement is not feasible, balloon valvuloplasty may serve as a “bridge” to valve replacement. Similarly, we have seen significant functional improvement in patients after balloon aortic valvuloplasty, so that some who initially were unable to undergo aortic valve replacement have improved to a point that either transcatheter or surgical replacement could be performed safely. In patients who need urgent noncardiac surgery, balloon valvuloplasty may be considered as a temporizing measure in the hope of reducing the risks of perioperative hemodynamic changes associated with anesthesia.

Many patients with severe aortic stenosis have comorbidities such as chronic obstructive pulmonary disease or liver or kidney disease that make it difficult to discern the degree to which aortic stenosis contributes to their symptoms. In such cases, the balloon procedure may provide a therapeutic answer; improvement of symptoms points to aortic stenosis as the driver of symptoms and may push for a more definitive valve replacement option.

Finally, in patients with no option for either transcatheter or surgical aortic valve replacement, balloon aortic valvuloplasty may be considered as a palliative measure.

The benefit of this procedure is only temporary, and restenosis generally occurs within 6 months. Therefore, its value as a stand-alone procedure is limited, and the overall survival rate is significantly improved only when it is used as a bridge to valve replacement.

It should be noted that balloon aortic valvuloplasty carries significant risk. The 30-day mortality rate may be as high as 10%, usually due to either aortic regurgitation (as a complication of the procedure) or persistent heart failure. Other complications occur in up to 15% of cases and include stroke, peripheral vascular complications (due to the size of the devices used and concomitant incidence of peripheral arterial disease), coronary occlusion, need for permanent pacemaker implantation, cardiac tamponade, and cardiac arrest. In patients who require a repeat procedure, it entails similar risks and outcomes as the first procedure.

Comment. Balloon aortic valvuloplasty holds an important place in the treatment of patients with severe aortic stenosis. In our experience, it is most often performed to bridge severely symptomatic patients to transcatheter or surgical aortic valve replacement, or to better understand the contribution of aortic stenosis to functional limitation in patients with multiple comorbidities. It has tremendous potential to alleviate symptoms and provide an opportunity for functional improvement, in turn allowing definitive treatment with aortic valve replacement and improved quality and quantity of life in patients with severe aortic stenosis.

MANAGING SEVERE STENOSIS IS FULFILLING, BUT CHALLENGING

Managing patients with severe aortic stenosis is very fulfilling but at the same time can be extraordinarily challenging. It requires a patient-by-patient analysis of clinical, echocardiographic, and hemodynamic data. In some cases, the relationship between aortic stenosis and current symptoms or future outcomes may be in doubt, and provocative testing or balloon aortic valvuloplasty may be necessary to provide further direction. A meticulous assessment, requiring the expertise of clinicians, imagers, interventionalists, and surgeons is often necessary to deliver optimal care to this group of patients.