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Aortic balloon valvuloplasty before transcatheter valve replacement in high-risk patients with aortic stenosis

Cardiac catheterization and echocardiographic hemodynamic study

Ballonvalvuloplastie der Aortenklappe vor Transkatheter-Aortenklappenersatz bei Hochrisikopatienten mit schwerer Aortenstenose

Herzkatheter- und echokardiographische hämodynamische Untersuchung

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Abstract

Background

Balloon aortic valvuloplasty (BAV) has been revived as a bridge to transcatheter aortic valve replacement (TAVR). The aim of the current prospective study was to define a safe time period from BAV to TAVR and to determine hemodynamic variables that predict event-free survival after BAV.

Patients and methods

The present prospective study included 68 consecutive patients with severe aortic stenosis who were treated initially with BAV from 2009 to 2012. Echocardiographic and invasive hemodynamic assessments were performed before BAV. The patients were followed up at regular intervals and events were defined as cardiac hospitalization or death.

Results

Invasive hemodynamic evaluation yielded more favorable results than echocardiographic assessment: aortic stenosis was less severe, cardiac output was higher, and pulmonary capillary wedge pressure (PCWP) was lower. Post-BAV event-free survival was 80.4 % at 30 days, 64.5 % at 6 months, 37 % at 1 year, 22.3 % at 2 years, and 9.3 % at 3 years. After excluding pre-discharge deaths (n = 7), the 30-day event-free survival rate was 90 %. Predictors of events after BAV were atrial fibrillation, cardiogenic shock, elevated euroSCORE (European System for Cardiac Operative Risk Evaluation), elevated PCWP, and elevated pulmonary artery systolic pressure. Invasively measured PCWP was the only independent predictor of events (hazard ratio, 1.07; 95 % confidence interval, 1.03–1.11; p = 0.001).

Conclusion

A 30-day post-BAV period may be considered a bridge to TAVR. Furthermore, invasive assessment of PCWP before BAV is an independent hemodynamic predictor of events after BAV.

Zusammenfassung

Hintergrund

Die Ballonvalvuloplastie der Aortenklappe (BAV) wird als Überbrückung bis zum Transkatheter-Aortenklappenersatz (TAVR) wieder häufiger eingesetzt. Das Ziel der vorliegenden Studie bestand darin, einen sicheren Zeitraum zwischen BAV und TAVR zu definieren und die hämodynamischen Variablen zu bestimmen, die nach der BAV ein ereignisfreies Überleben vorhersagen können.

Methode

Die vorliegende prospektive Studie umfasst 68 Patienten mit schwerer Aortenstenose, die von 2009 bis 2012 mit einer BAV behandelt wurden. Vor der BAV wurden eine echokardiographische sowie eine invasive hämodynamische Untersuchung durchgeführt. Alle Patienten wurden in regelmäßigen Abständen nachuntersucht, als Ereignisse waren kardial bedingter Krankenhausaufenthalt oder Tod definiert.

Ergebnisse

Die invasive hämodynamische Untersuchung führte zu günstigeren Ergebnissen als die Echokardiographie: weniger ausgeprägte Aortenstenose, größeres Herzzeitvolumen und niedrigerer Lungenkapillardruck (PCWP). Die ereignisfreie Überlebensrate nach BAV betrug 80,4 % nach 30 Tagen, 64,5 % nach 6 Monaten, 37 % nach einem Jahr, 22,3 % nach 2 Jahren und 9,3 % nach 3 Jahren. Nach Ausschluss der Todesfälle vor Krankenhausentlassung (n = 7) lag die ereignisfreie Überlebensrate nach 30 Tagen bei 90 %. Prädiktoren für Ereignisse nach BAV waren Vorhofflimmern, kardiogener Schock, erhöhter euroSCORE (European System for Cardiac Operative Risk Evaluation), PCWP und erhöhter systolischer pulmonalarterieller Druck. Der invasiv gemessene PCWP war der einzige unabhängige Prädiktor für Ereignisse (Hazard Ratio 1,07; 95 %-Konfidenzintervall 1,03–1,11; p = 0,001).

Schlussfolgerung

Eine Phase von 30 Tagen nach der BAV könnten als Überbrückungszeitraum bis zur TAVR in Betracht gezogen werden. Dabei stellt der vor der BAV invasiv bestimmte PCWP einen hämodynamischen unabhängigen Prädiktor für Ereignisse nach BAV dar.

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Acknowledgments

Kamperidis received a European Society of Cardiology training grant, Heart House, France, and a Hellenic Cardiological Society training grant, Athens, Greece. S.A. Mouratoglou received a Hellenic Cardiological Society training grant, Athens, Greece.

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Authors and Affiliations

  1. 1st Department of Cardiology, AHEPA University Hospital, Stilponos Kiriakidi 1, P.O. 54636, Thessaloniki, Greece

    V. Kamperidis, S. Hadjimiltiades, S.A. Mouratoglou, A. Ziakas, G. Sianos, A. Sarafidou, I. Ventoulis, G. Kazinakis, G. Giannakoulas, G.K. Efthimiadis, G. Parcharidis & H. Karvounis

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Correspondence to V. Kamperidis.

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V. Kamperidis, S. Hadjimiltiades, S. A. Mouratoglou, A. Ziakas, G. Sianos, A. Sarafidou, I. Ventoulis, G. Kazinakis, G. Giannakoulas, G. K. Efthimiadis, G. Parcharidis, and H. Karvounis state that there are no conflicts of interest.

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Kamperidis, V., Hadjimiltiades, S., Mouratoglou, S. et al. Aortic balloon valvuloplasty before transcatheter valve replacement in high-risk patients with aortic stenosis. Herz 41, 144–150 (2016). https://doi.org/10.1007/s00059-015-4353-9

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