Pre-implantation balloon-aortic valvuloplasty before transcatheter aortic valve implantation: is this still needed?

Abstract

Balloon aortic valvuloplasty (BAV) has historically been recommended prior to transcatheter aortic valve implantation (TAVI). Pre-implantation BAV (pBAV) creates fractures at the level of calcified leaflets, thereby facilitating delivery of the transcatheter valve system across the diseased aortic valve and, enhances prosthesis implantation and expansion within the calcified aortic valve annulus. New device designs, lower profile delivery systems and increasing operator experience have enabled direct-TAVI (without pBAV), and its appeal amongst TAVI operators enhanced the dissemination of a direct TAVI approach across many centres. In this review, we discuss contemporary evidence that inform the debate on the need for routine pBAV for TAVI candidates and present a framework that may assist operators in selecting patients for pBAV.

Combination Use of Inoue-Balloon and Self-Expandable Transcatheter Valves in Managing Aortic Stenosis Not Amenable to Balloon-Expandable Valves

“…Our results suggest that pre-and postdilation balloon sizes may differ to ensure a safe procedure, particularly in complex and challenging cases with eccentric calcified valves and bicuspid anatomy (usually with a bulky leaflet or elliptical annulus) or selfexpandable valves. 6,9,[25][26][27] One concern of using Inoue-Balloon catheter for post-dilation is excessive dilation of the proximal and distal portions of the balloon more than the stipulated label size, which is potentially related to the deformation and durability of the transcatheter valves. However, in an invitro model, the proximal and distal parts of the Inoue-Balloon catheter were not found to be over-dilated compared with those without silicone valve models (Figure 5).…”

Impact of balloon predilatation in patients with reduced versus preserved ejection fraction during transcatheter aortic valve implantation

“…Predilatation before TAVI has several advantages: it facilitates deliverability and optimal valve deployment, thereby reducing the risk of PVL and the need for post-dilatation which may carry the risk of device embolization or annulus rupture and may affect the long-term durability of the valve. 9…”

“…Accordingly, the operator can decide to either abort the TAVI procedure or consider preventive measures like prophylactic guidewire engagement of the left coronary system at risk or use of a specific type of transcatheter heart valves (THV). 9…”

“…Also, patients with pre-existent low flow-low gradient aortic stenosis, severe aortic regurgitation, severe left ventricular systolic dysfunction, or severe pulmonary hypertension may be at high risk of acute decompensation and hemodynamic instability after predilatation. 9,15…”

“…Predilatation before TAVI has several advantages: it facilitates deliverability and optimal valve deployment, thereby reducing the risk of PVL and the need for post-dilatation which may carry the risk of device embolization or annulus rupture and may affect the long-term durability of the valve. 9 Also, predilatation helps to predict the risk of left main (LM) coronary artery obstruction during TAVI, which results from displacement of the native valve leaflets over LM ostia. 10 This can be done by assessing the interaction of the displaced leaflets with the coronary ostia during predilatation.…”