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BALLOON AORTIC VALVULOPLASTY
This document discusses balloon aortic valvuloplasty (BAV) as a treatment for aortic stenosis. It can be performed via either a retrograde or antegrade approach. The retrograde approach involves crossing the aortic valve from the femoral artery, while the antegrade approach involves transseptal catheterization from the femoral vein. Key steps for both approaches include rapid ventricular pacing to stabilize the heart during balloon inflation. The goals of BAV are to increase the aortic valve area and reduce pressure gradients. Complications can include hypotension, aortic regurgitation, and embolization of calcium deposits. BAV provides symptomatic relief but is usually not curative, as restenosis may occur.
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Aortic stenosis (AS) is common in older adults. Surgical options include SAVR and BAV, with TAVI for high-risk patients.
Aortic stenosis (AS) is common in older adults. Surgical options include SAVR and BAV, with TAVI for high-risk patients.
Goals of BAV include doubling valve area and symptomatic improvement. BAV relies on mechanisms involving fracturing calcified nodules.
Two approaches: retrograde and antegrade. Steps include patient prep, guidewire use, balloon inflation.Detailed preparation steps include sedation, access setup, and monitoring during valve procedures.
Two approaches: retrograde and antegrade. Steps include patient prep, guidewire use, balloon inflation.
Two approaches: retrograde and antegrade. Steps include patient prep, guidewire use, balloon inflation.
Two approaches: retrograde and antegrade. Steps include patient prep, guidewire use, balloon inflation.
Detailed preparation steps include sedation, access setup, and monitoring during valve procedures. Post-BAV immediate care entails hemostasis and monitoring. Results show improvement in valve area and gradient.
Post-BAV immediate care entails hemostasis and monitoring. Results show improvement in valve area and gradient. Complications in BAV procedures include procedural death and vascular issues. Perspectives on usage are limited.
Complications in BAV procedures include procedural death and vascular issues. Perspectives on usage are limited.
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BALLOON AORTIC VALVULOPLASTY
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- 2. Introduction Aortic stenosis(AS) is the most common form of adult valvular heart disease, more prevalent in the aging population. Surgical Aortic Valve Replacement (SAVR) is the treatment of choice, only definitive treatment to relieve symptoms or to improve survival. Despite extensive/exhaustive guidelines and recommendations one third of patients are not referred to surgery – because of old age, left ventricular dysfunction and comorbidities. Balloon Aortic Valvuloplasty (BAV) fills the gap and its successor Transcatheter Aortic Valve Implantation (TAVI) will be an option for the surgical high risk patients.
- 6. Otto et alN Engl J Med 1999;341:142–7
- 7. Ideal patient Palliative procedure BRIDGETO SURGERY Frail patients Extremely old Compromised clinical status from concomitant CAD and other extracardiac comorbidities.
- 8. Indications for BAVin adults Cardiogenic shock. Bridge to aortic valve surgery. Symptomatic critical AS requiring emergency noncardiac surgery. Poor surgical candidate owing to high risk – age > 90 yrs. Diagnostic testing in low gradient/low output setting Congenital aortic stenosis Rheumatic aortic stenosis Predilatation before TAVI
- 10. Circulation March 27,2007 vol. 115 no. 12e334-e338
- 11. Goals A 100%increase in the aortic valve area. Symptomatic improvement
- 12. Maximum pressureexerted on the valve leaflets during balloon inflation. Proper balloon sizing. Optimal contact with the valve structures. Final valve area is a determinant of the prognosis.
- 13. Why BAV isnot successful as that of PBMV? The results of BAV are limited by the pathology involved in the disease. Degenerative AS is MC etiology. Chronic inflammatory process. Commissural fusion is not the predominant feature in majority of older patients with calcific AS. Fracture of nodular calcium deposits – leaflet mobility improved – increased valve opening – blood flow increased during LV contraction.
- 14. MECHANISMS OF ACTION Theeffects of BAV on stenosed aortic valves are poorly understood, but several mechanisms appear likely. • Primarily, balloon-induced fracturing of calcified nodules creates hinge points, which along with the creation of cleavage planes in collagenous stroma, results in improved leaflet flexibility and valve opening. • Separation of fused leaflets is uncommon given its infrequent occurrence in this patient population with calcific aortic stenosis. • Enhanced compliance or stretching of the adjacent annulus and calcified aortic root has also been suggested.
- 15. When maximally inflated,a 20-mm diameter balloon (occupying a 3.14 cm2 cross-sectional area) significantly enlarges the stenosed valve orifice by 3 mechanisms: stretching of valve tissue, rupturing of commissural fusion and breaking of calcific deposits. These last 2 mechanisms are the most effective, in both tricuspid and bicuspid forms of AS, to render the cusps more flexible . Stretching alone may give only a temporary increase in valve area with an elastic return of the leafle to their initial stenosing position and may explain, at least in part, the occurrence of restenosis. Inflation of the balloon is well tolerated with no deleterious decrease in blood pressure in two-thirds of the cases because the balloon opens the commissures, allowing blood ejection through these openings. It does not produce calcific emboli, probably because calcium deposits remain imbedded in the leaflets, covered by the endothelium. Finally, it very infrequently produces acute severe aortic regurgitation. Careful choice of balloon size is necessary to obtain on effective opening; most often a 20-mm diameter balloon but sometimes a balloon up to 23 mm is used. Am J Cardiol. 1988 Dec 1;62(17):1241-7 http://www.ncbi.nlm.nih.gov/pubmed/3195485
- 16. Two approaches Retrogradeapproach Antegrade approach
- 17. The Retrograde approach First described by Lababidi in infants and children. Alain Cribier et al in adults. Procedure time < 1 hr. Less complications Dr.Zuhdi Lababidi
- 18. Steps in theprocedure Patient preparation. Equipments – guidewires,sheath,balloon catheters. Retrograde crossing of the native aortic valve. Rapid ventricular pacing (RVP) Balloon inflation. Simultaneous gradients across the aortic valve Hemostasis.
- 19. Patient preparation Mildsedation with IV midazolam, local anaesthesia. Femoral arterial and venous access – 8F sheath. UFH 3000-5000IU IV at start of procedure. Coronary angiography in the same sitting, if needed coronary intervention will also be done after BAV. Right heart catheterization – Swan Ganz thermodilution catheter. For TAVI – Supraaortic angiography – shallow LAO, followed by abdominal and pelvic angiography.
- 20. Guidewire Extra stiffAmplatz 0.035”, 270 cm length guidewire (Cook,Bjaeverskov,Denmark) All catheter exchanges. Stabilizing the valvuloplasty balloon during Inflation. Deflation Withdrawal Large pigtail shaped curve is formed at the distal end of the wire with a dull instrument to prevent ventricular perforation and to decrease ectopy.
- 22. Sheaths 8F arterialsheath is replaced over the extrastiff wire with a 10F,12F or 14F sheath, depending on the balloon catheter required. Reduction in the profile of the devices – reduces local complications at the femoral artery puncture site. 12-14 F sheaths – hemostasis by preclosing with a 10F Prostar device (Prostar, Abbott Vascular, Redwood City,Ca). 10 F sheath – 8F angioseal device (Angioseal Vascular closure device,St Jude Medical,Belgium) at the end of the procedure.
- 23. Balloon catheters Tyshakballoon – retrograde technique Inoue balloon – antegrade technique Double balloon technique – antegrade Catheters /Balloons Sheath size/ length of balloons Double sized Cribier Letac catheters. 12-14 F Z med II balloon catheter (Numed Inc.,Hokinton NY, USA). 12-14 F Cristal balloons (Balt Extrusion,Montmorency,France) 10 F 23 mm diameter balloons(usually used) 45 mm 25 mm diameter balloon 50 mm 20 mm diameter balloon (if < 19 mm on echocardiography, densely calcified) 45 mm 25 mm diameter balloon (if aortic annulus diameter is >24 mm, 25% cases)
- 24. Retrograde crossing ofthe aortic valve AL -2 commonly used. Dual multilumen or pigtail catheter – peripheral augmentation is absent. Straight tip, fixed core ,0.035” guide wire. 40LAO – catheter positioned at the rim of the valve. Catheter is slowly pulled back, firm clockwise rotation maintained to direct the catheter tip toward the centre of the valve plane. Guidewire is carefully moved in and out of the catheter tip, sequentially mapping the valve surface and exploring the valve orifice. Once as the wire crosses, the catheter positioned at the middle of LV. Transvalvular gradient is obtained from the side arm of the femoral sheath. Cardiac output measured. Aortic valve area by Gorlin’s equation.
- 26. Rapid ventricular pacing(RVP) 6F temporary bipolar pacing lead – RV posterior wall Pulse generator – 200 to 220 beats/min Effective pacing is – precipitous fall in blood pressure to at least 50 mm Hg. Initial 200/min – no response – increase to 220/min If 2:1 block is seen,rate is reduced to 180 beats/min or modify the lead position. Demand mode at 80 /min - in case of VAGAL response, AV conduction interruption leading to bradycardia or asystole in repsonse to balloon inflation. In the past, before the use of RVP, always challenging to maintain the balloon in the optimal position during balloon inflation.
- 27. Figure 3. Rapidventricular pacing stabilises the balloon when it is inflated. A pacing catheter is placed in the right ventricle. Rapid ventricular pacing is initiated at approximately 180–220 bpm and temporarily leads to a drop in systemic pressure. The balloon is inflated only after the pacing rate is reached and the blood pressure drops, and pacing is also continued until the balloon is deflated
- 29. Contrast solution Shortextension tubing with a three way stop cock attached is connected to a hand held 30 ml leur lock syringe filled with diluted contrast. Contrast dilution at 15% contrast to 85% saline – reduces viscosity - facilitates inflation, deflation cycles.
- 30. Further steps inBAV Diagnostic catheter is removed from the LV over the extrastiff wire Looped flexible segment of wire is carefully maintained in the LV cavity. 8F sheath is replaced by the 10F sheath over the extra stiff wire. After flushing the distal lumen and applying negative pressure on the balloon port, the balloon catheter is mounted on the extra stiff wire. The system advanced into the aorta and allowed to rest above the aortic valve. Partial inflation and then completely deflated one or more times to completely purge it of air bubbles.
- 31. Cont… De airingof the balloon in the ascending aorta – lowest balloon profile while crossing the aortic arch – decreasing the risk of atheromatous plaque dislodgement and embolization. Balloon catheter is advanced across the aortic valve centering the valve between two markers. The inflated balloon would tend to pop into the LV abruptly, striking the apex,or would “eject” itself back into the aorta with the possibility of disrupting atheromatous plaque,which would embolize.
- 32. Balloon inflation Clearcommunication between the operators manipulating the balloon catheter and the pacing device. RVP and simultaneous forward pressure on the balloon catheter and forward pressure on the extra stiff wire help stabilize the balloon during inflation. Traction on the guidewire causes forward movement on the balloon. Pushing the guidewire displaces the balloon in the aortic direction allowing for better positioning. RVP turned on, balloon inflation is started quickly and with enough pressure to rapidly inflated the balloon as soon as the blood pressure falls. RVP continued for few seconds after the balloon reaches the maximum inflation. Balloon is rapidly deflated, pacer is turned off, the balloon withdrawn from the valve – clear coordination is required to allow restoration of antegrade flow while maintaining safe wire position in LV.
- 33. Figure 1. Balloonaortic valvuloplasty (BAV) via the retrograde approach. After correctly positioning across the stenotic valve the balloon is inflated with dilute contrast material. Note the temporary pacing wire in the right ventricle and the pigtail shaping of the left ventricular wire
- 35. Rapid balloondeflation and restoration of blood flow were important to minimize the time of hypoperfusion and hypotension. Allow time for heart and BP to return to preinflated parameters before proceeding to inflate the balloon again. Observe the wave form of the aortic pressure tracing, as well as heart rate response, rhythm and BP recovery. A sudden change in waveform with loss of dicrotic notch or falling diastolic pressure could indicate the presence of severe AR. Improvement of the pressure slope is suggestive of successful procedure.
- 36. Particular caremust be taken as the deflated balloon is drawn through the sheath. If resistance encountered, remove the catheter and sheath as a single unit. Residual gradient – simultaneous measurement of pressure in the LV and in the aorta. Significant gradient – next larger balloon may be chosen and the sequence is repeated.
- 37. Final steps Pullback gradient is obtained after the final balloon inflation. Remove the pacemaker. Cardiac output is measured. Final aortic valve area is calculated. Supraaortic angiography – for presence and severity of AR. If contrast not used,assessment can be by TTE.
- 38. Figure 2. Aorticand left ventricular traces pre- and post-valvuloplasty. The mean aortic pressure gradient has reduced significantly from 50 mmHg to 25 mmHg
- 39. Optimal result Doublingof the valve area. Decreasing the gradient by 50% compared with the baseline value.
- 40. Immediate management afterBAV Manual compression is used for hemostasis at the venous entry site. Arterial hemostasis is achieved with closure device. Pneumatic pressure device in case of technical failure. Uncomplicated cases – discharge in 2 days. In case of severe CHF or cardiogenic shock – monitoring in ICU with inotropic support is required. MC cause of hypotension – vagal reactions. Pericardial tamponade or retroperitoneal bleed not to be forgotten.
- 41. Antegrade approach Blockand colleagues Transseptal approach. Severe peripheral vascular disease. Dr.Peter.C.Block
- 42. Steps in theprocedure Patient preparation Transseptal catheterization Crossing the aortic valve. Atrial septostomy Antegrade balloon aortic valvuloplasty
- 43. Patient preparation MildIV sedation and local anaesthesia. Femoral venous access bilaterally obtained – 8F sheath in Rt. femoral vein and 6F sheath in Lt. femoral vein. Coronary angiography through 6F sheath – brachial(or radial) artery. Pigtail placed above the aortic valve. Right heart catheterization and baseline hemodynamics measurements are recorded. Left femoral vein access, bipolar pacing catheter –RV apex. RVP as needed.
- 44. Trans septal catheterization 8F Mullins sheath. Brockenbrough needle via the right femoral vein. Crossing the septum – left lateral view. A pigtail catheter is positioned in the ascending aorta through out the procedure for monitoring the blood pressure, as a reference marker for the trans septal puncture. Middle third of a virtual line connecting the distal tip of the pigtail catheter adjacent to the aortic calcification and the posterior border of the heart. After entry into LA is confirmed, then UFH 5000 IU is administered IV. 7F Swan Ganz catheter which has an inner lumen compatible with a 0.035 inch guidewire across the mitral valve into the LV Under fluoroscopic guidance - 40 RAO projection. Trans aortic gradient - Swan Ganz in LV and pigtail in aorta. Aortic valve area calculated by Gorlin’s equation.
- 45. Crossing the aorticvalve Mullins sheath is advanced approx. 2cm beyond the mitral valve. Balloon of the Swan Ganz catheter is inflated and directed into the LVOT approaching the native aortic valve. A 0.035’’ straight wire may facilitate crossing the aortic valve with the balloon deflated, as the catheter pushed over the wire into the ascending aorta. Wire is removed, and the balloon is reinflated. Catheter is advanced into the descending aorta and positioned at the level of the distal aortic bifurcation with an Amplatz 0.035” ,360 cm long extrastiff guidewire. Balloon is deflated and the catheter is removed.
- 46. The “essential” guidewireloop in the left ventricle Large loop in the guidewire to be kept in the left ventricle. Straightening of the guidewire between the mitral valve and the aortic valve can keep the mitral valve open, resulting in severe mitral regurgitation with hemodynamic deterioration. Loop within the left ventricle is maintained with continuous monitoring at each step of the procedure. 8F sheath is replaced with a 10 F sheath for the subsequent balloon dilatation using the cristal balloon catheter (12F or 14F if NuMed balloons are used).
- 47. Atrial septostomy Theatrial septum is dilated with an 8mm diameter balloon septostomy catheter through the 10 F sheath in the right femoral vein. Diluted solution of contrast media:saline (15:85) is used with a 10 ml syringe for atleast two balloon inflations of 30 seconds each.
- 48. Antegrade Balloon AorticValvuloplasty Same balloon catheters are used as for retrograde approach. Dilatation of the aortic valve is done preferentially with the 23 mm diameter balloon, which is advanced through the 10 F sheath and positioned across the aortic valve, while the loop is maintained in the LV. Same steps as in retrograde technique. Not feasible to measure the gradient after inflations of each diameter of balloon with this technique. Aortic pressure waveform for the hemodynamic result.
- 50. If asignificant fall in diastolic pressure does not occur, then the next larger balloon size can be chosen. When two or three inflations using the largest selected balloon size are completed, the balloon catheter is removed. A 6F pigtail catheter is advanced over the extrastiff wire and positioned over the arch so that the wire can be removed shielded by the catheter, thus avoiding injury to the aorta or the mitral valve.
- 51. Final gradient– pigtail in the LV and other catheter in the aorta. Supra aortic angiogram can be obtained. Pacing catheter can be removed if there is no AV conduction defect. Swan Ganz catheter for the final hemodynamic results. Hemotasis is obtained by manual compression over the artery and the vein after sheath removal. Bed rest for 24 hours. ICU monitoring required for patients who presented in caridogenic shock.
- 52. Results using contemporaryBAV techniques. 141 consecutive patients Severe Aortic stenosis – high risk for surgery or inoperable January 2002 to April 2005 Average age was 80.3±10 years. 45 % were women NYHA IV -80% LVEF < 30% - 28% Emergency procedure in cardiogenic shock – 5.6% cases Retrograde approach in 95% of the cases. Largest balloon used was 23 mm balloon size – 84% of the procedures. Agatiello C,Eltchaninoff H et al.Arch Mal Coeur 99;195-200:2006.
- 53. Results Immediate results Increase inaortic valve area from 0.59± 0.19 to 1.02± 0.34 cm² (p<0.001) Decrease in transvalvular gradient from 49.3± 21.2 to 22.2± 11.8 mm Hg (p<0.001) Post BAV AR grade 2 – 14%, grade 3 – 3.5%,grade 4 1.4 % cases. Death – 6 patients (4%) Nonfatal severe complications – 9 patients (6%) - 2 transient strokes,5 complete AV block,2 severe AR. Vascular complications – 8,no surgical repair. Discharge from the hospital was at 5.6± 3 days. Clinically apparent neurological deficit - < 2%. Embolization of atheromatous debris – rare. Agatiello C,Eltchaninoff H et al. Arch Mal Coeur 99;195-200:2006.
- 54. Comparisons of complicationrates in the Rouen Series and in the Mansfield Registry Complications Mansfield Scientific Aortic Valvuloplasty Registry 1986-1988 (N=492) Rouen Series 2002-2005 (N=141) Procedural death 2(4.9%) 3 (2.1%) Post procedural death (<7 days) 12(2.6%) 3(2.1%) Cerebral embolic events 11(2.2%) 2(1.4%) Transient ischemic attacks 5(1.1%) 0(0%) Ventricular perforation with tamponade 11(2.2%) 0(0%) Severe AR 5(1.1%) 2(1.4%) Vascular complications (surgical repair) 27(5.5%) 0(0%) Non fatal arrhythmias 5(1.1%) 5(3.5%) MI,sepsis,renal failure 8(1.6%) 1(1%)
- 56. Non calcific aorticstenosis Predominantly fibrotic – well suited for BAV. Procedure effective in 80-90% cases. Mortality rate of approx. 0.7%. Survival at 8 yrs - 95% Need for repeat intervention of 25% at 4yrs and 50% at 8 yrs. Rosenfeld et al – no deaths,no embolic events. Intermediate follow up at 38 months - 50% patients required no further intervention.
- 58. Current perspectives ofBAV No Class I or IIA Recommendations for BAV. Class II B Recommendations for adult patients with severe AS are 1.hemodynamic unstable patients, candidates for bridge to surgery. 2.as a palliative procedure for patients with severe comorbid conditions which would preclude AVR. 3.criticalsymptomatic AS 4.contributing role of AS to dyspnea in patients with severe lung disease. 5.to assess myocardial contractile reserve in patients with lowgradient or low EF.