Aortic stenosis valvuloplasty
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]
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Aortic Stenosis Microchapters |
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Diagnosis |
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Treatment |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
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Transcatheter Aortic Valve Replacement (TAVR) |
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Case Studies |
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Aortic stenosis valvuloplasty On the Web |
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American Roentgen Ray Society Images of Aortic stenosis valvuloplasty |
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Directions to Hospitals Treating Aortic stenosis valvuloplasty |
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Risk calculators and risk factors for Aortic stenosis valvuloplasty |
Overview
Aortic valve replacement procedure is the mainstay of treatment of aortic stenosis as it improves both symptoms and life expectancy. Minimally invasive methods of treatments such as percutaneous aortic balloon valvotomy (PABV) maybe the best alternative for surgery in patients whom have severe comorbidities and whom considered to have a highest risk surgery. PABV is a procedure in which 1 or more balloons are placed across a stenotic valve and inflated to decrease the severity of aortic stenosis. Transcatheter aortic valve implantation is another good alternative as well, although both have their own limitations.
Indications
ACC/AHA guidelines concluded that percutaneous aortic balloon valvotomy (PABV) is not a substitute for valve replacement in adults in all cases. although there are some exceptions. ACC/AHA guidelines below for percutaneous aortic balloon valvotomy (PABV) indicate the presence of two settings in which such procedure could be done. Some studies showed that this method is preferable to surgery in children and young adults with congenital, noncalcific AS. Adults with severe calcific AS are not good candidates for this procedure as there is high restenosis rate and high risk of complications.
ACC/AHA Guidelines- Indications for Percutaneous Aortic Balloon Valvotomy (DO NOT EDIT) [1]
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Class IIb1. Aortic balloon valvotomy might be reasonable as a bridge to surgery in hemodynamically unstable adult patients with AS who are at high risk for AVR. (Level of Evidence: C) 2. Aortic balloon valvotomy might be reasonable for palliation in adult patients with AS in whom AVR cannot be performed because of serious comorbid conditions. (Level of Evidence: C) Class III1. Aortic balloon valvotomy is not recommended as an alternative to AVR in adult patients with AS; certain younger adults without valve calcification may be an exception. (Level of Evidence: B) |
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Percutaneous Aortic Balloon Valvotomy (PMBV) Technique
- After preparing the patient, a guide wire is inserted through the femoral artery into the aorta. The stenotic aortic valve is crossed, this may require multiple attempts and a long time.
- A long sheath is introduced over the guide wire, through the sheath a Mansfield balloon is introduced and positioned across the aortic valve.
- The balloon is manually inflated using a large syringe filled with dilute contrast. If there is difficulty in maintaining the balloon across the aortic valve during inflation, temporary ventricular pacing at high rate can reduce the cardiac output and give stability to the balloon.
- Balloon is deflated and the trans valvar gradient reassessed for success of the procedure. Repeated dilatations can be given if necessary.
- The balloon should be de-aired and filled with dilute contrast to avoid the chance of air embolism in case of balloon rupture during dilatation.
Outcome
There is a small but significant risk of development of aortic regurgitation during the procedure which can lead to pulmonary edema. Certain types of balloons can rupture while attempting to dilate a calcified valve as a palliative procedure. Immediately after the procedure; a moderate reduction in the transvalvular pressure gradient is seen. The valve area after the procedure rarely exceeds 1.0 cm2 but an early symptomatic improvement is usually seen.
Sources
- 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [1].
References
- ↑ 1.0 1.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.