Balloon aortic valvuloplasty in high risk aortic stenosis patients with left ventricular ejection fractions <20%.

OBJECTIVES: To determine outcomes following balloon aortic valvuloplasty (BAV) in aortic stenosis (AS) patients with a left ventricular ejection fraction (LVEF) <20%. BACKGROUND: Severe AS patients with a LVEF <20% are excluded from United States (U.S.) transcatheter aortic valve replacement (TAVR) trials and often surgical aortic valve replacement (AVR). The role for BAV to enhance LVEF is unclear. METHODS: Our BAV database of 270 consecutive patients extending from 2005 through 2010 was queried for a preoperative LVEF <20%. Demographics, echocardiograms, procedural technique, and outcomes were analyzed. Pre- and postoperative echocardiograms were used to determine improvement in aortic valve area (AVA) and LVEF. RESULTS: Sixteen patients were identified with a median age of 82 years. The composite Society of Thoracic Surgeons' (STS) mortality risk was 16.4%. The median preoperative AVA and LVEF were 0.60 cm(2) and 16%, respectively, and postoperative AVA and LVEF were 0.77 cm(2) and LVEF 19%, respectively. About 15 of the 16 patients had postoperative echocardiograms available for comparison. And 7 of these 15 (47%) demonstrated improvement in LVEF to ≥20% (median LVEF 25%). The absence of coronary disease and improvement in AVA of ≥0.2 cm(2) was associated with postoperative LVEF of ≥20%. Procedural mortality was 0%. The 30-day, 6-month, and 1-year survival was 69%, 56%, and 29%. STS's mortality risk score ≥15% was associated with short-term mortality. CONCLUSION: With appropriate technique, BAV can be reasonably safe in patients with LVEF <20%. Roughly half of these patients demonstrated improvement in LVEF to ≥20%.

Comparison of outcomes in high-risk patients>70 years of age with aortic valvuloplasty and percutaneous coronary intervention versus aortic valvuloplasty alone.

The goal of this study was to compare outcomes of combined balloon aortic valvuloplasty (BAV) plus percutaneous coronary intervention (PCI) with BAV alone in a surgically high risk, older (>70 years) population with both aortic stenosis (AS) and coronary artery disease (CAD). The medical records, coronary angiograms, and procedural reports of 100 consecutive patients who underwent BAV and coronary angiography at our institution from July 2003 to November 2006 were reviewed. Seventeen patients (mean age 86.2+/-6.4 years) underwent combined (nonstaged) BAV and PCI with a calculated Society of Thoracic Surgery risk score of 13.5%+/-6.7; 13 of these underwent coronary stenting before BAV and 4 after BAV. All 17 patients were successfully treated with this combined strategy. The incidence of periprocedural mortality, myocardial infarction, and stroke was zero. An additional 25 patients (mean age 85.9+/-6.9) with CAD were identified who underwent BAV alone with a Society of Thoracic Surgery risk score of 12.6+/-5.7%. PCI in these patients was avoided primarily because of greater lesion complexity or a perceived low probability of symptomatic benefit. There was 1 procedural death, no myocardial infarction, and 1 postprocedural stroke in these 25 patients. The procedural duration and hospital length of stay for the combined BAV and PCI group was 98.8+/-17.6 minutes and 4.1+/-2.8 days, respectively, and for the BAV only group was 86.2+/-27.3 minutes and 3.3+/-2.1 days, respectively. In conclusion, with appropriate selection, BAV plus PCI was safely performed in this retrospective series of elderly, high-risk patients with severe AS and CAD.

Feasibility of transcatheter intervention for severe aortic stenosis in patients >or=90 years of age: aortic valvuloplasty revisited.

OBJECTIVES: The goals of this study were to determine the feasibility, safety, and early outcomes of balloon aortic valvuloplasty (BAV) for severe aortic stenosis in a nonagenarian population. BACKGROUND: This very elderly population is expanding rapidly, has a high incidence of aortic stenosis, and uncommonly undergoes surgical aortic valve replacement. These patients may best be treated with a transcatheter approach due to comorbidities, surgical risk, and personal preference. METHODS: We reviewed 31 consecutive patients >or=90 years of age who underwent BAV at our institution from July 2003 to August 2006 for data pertinent to patient characteristics, procedural techniques, and 30-day outcomes. RESULTS: Our patients had a mean age of 93 +/- 3.0 years (90-101). The society of thoracic surgery risk score was 18.5 (+/-10.2) and logistic Euroscore was 35.8 (+/-19.3). Twenty-five patients (81%) underwent retrograde BAV and 6 (19%) antegrade BAV. Five patients (16%) underwent combined BAV and coronary stenting. Overall mean aortic valve area increased from 0.52 cm2 (+/-0.17) to 0.92 cm2 (+/-0.22) and mean New York Heart Association (NYHA) functional class improved from 3.4 to 1.8. Intraprocedural mortality occurred in one patient (3.2%) and 30-day mortality in three patients (9.7%). CONCLUSIONS: BAV can be carried out in high risk nonagenarian patients with an acceptable complication rate, low perioperative mortality, and early improvement in NYHA functional class.

Radiation following percutaneous balloon aortic valvuloplasty to prevent restenosis (RADAR pilot trial).

OBJECTIVES: We wished to determine the feasibility and early safety of external beam radiation therapy (EBRT) used following balloon aortic valvuloplasty (BAV) to prevent restenosis. BACKGROUND: BAV for calcific aortic stenosis (AS) has been largely abandoned because of high restenosis rates, i.e., > 80% at 1 year. Radiation therapy is useful in preventing restenosis following vascular interventions and treating other benign noncardiovascular disorders. METHODS: We conducted a 20-patient, pilot study evaluating EBRT to prevent restenosis following BAV in elderly patients with calcific AS. Total doses ranging from 12-18 Gy were delivered in fractions over a 3-5 day post-op period to the aortic valve. Echocardiography was performed pre and 2 days post-op, 1, 6, and 12 months following BAV. RESULTS: One-year follow-up is completed (age 89 +/- 4). There were no complications related to EBRT. Eight patients died prior to 1 year; 5 of 10 (50%) in the low-dose (12 Gy) group and 3 of 10 (30%) in the high-dose (15-18 Gy) group. None of these 8 patients had restenosis, i.e., > 50% loss of the initial AVA gain, and only three deaths were cardiac in origin. One patient underwent aortic valve replacement and none repeated BAV. By 1 year, 3 of the initial 10 (30%) in the low-dose group and 1 of 9 (11%) in the high-dose group demonstrated restenosis (21% overall). CONCLUSIONS: EBRT following BAV in elderly patients with AS is feasible, free of early complications, and holds promise in reducing the 1 year restenosis rate in a dose-dependent fashion.

Successful rotational atherectomy in the setting of extensive coronary dissection: a case of failed balloon angioplasty in a nondilatable calcified lesion complicated by balloon rupture and extensive dissection.

We describe a case of rotational atherectomy (RA) used in the setting of extensive coronary dissection. Unsuccessful predilitation of a heavily calcified proximal LAD stenosis resulted in balloon rupture, which produced occlusive dissection extending into the mid LAD. Limited options for this patient required that we perform RA to permit stent delivery and deployment and avoid anterior myocardial infarction. A brief discussion of reasons for balloon angioplasty failure and the potential role for subsequent RA is given. Predictors for coronary perforation when performing RA are reviewed. Our rationale and strategy to avoid the increased risk of perforation with RA in this contraindicated setting of extensive dissection is given.