Is there still a role for balloon aortic valvuloplasty in the TAVR era?

In the pretranscatheter aortic valve replacement (TAVR) era, balloon aortic valvuloplasty (BAV) was used as a palliative procedure for patients considered inoperable for surgical aortic valve replacement (SAVR). BAV, however, did not provide effective long-term relief of aortic stenosis (AS) symptoms, and was associated with recurrent AS, aortic insufficiency, and strokes due to embolization. Its major role was to determine which high-risk patients may have resolution of their AS symptoms andwould benefit from SAVR. TAVR has now replaced BAV as the treatment of choice for inoperable patients with symptomatic, severe AS whose life expectancy is greater than 1 year (Class IB). However, many inoperable patients with AS also have severe comorbidities such as chronic obstructive pulmonary disease (COPD), severe tricuspid regurgitation, end-stage renal disease requiring dialysis, hepatic dysfunction, and frailty which have been shown to limit 1-year survival following TAVR. This is especially true for patients with COPD, whose symptoms of dyspnea may be more related to poor lung function rather than AS. Therefore, prior to proceeding with an expensive intervention such as TAVR, which may not improve quality of life, it is important to determine which patients are dying from, and not with, AS. BAV may help to identify those patients, especially patients with COPD, whose symptoms are primarily due to AS and would benefit from TAVR. However, many of these patients also have significant peripheral vascular disease or have had prior cardiac surgery, which limits potential access sites for BAV procedures. Furthermore, the addition of either a minithoracotomy or limited sternotomy incision for direct aortic access may result in further impairment of respiratory function in those patients with severe COPD and should be avoided. In this edition of the Journal, Samuel et al report a new technique for performing BAV in patients with limited access. Their patient, a 75-year-old female s/p a right bilobectomy for an adenocarcinoma, presented with class 3 New York Heart Association symptoms of exertional dyspnea. Her echo was consistent with severe AS, but her diffusion capacity was only 37% of predicted, she had stage 4 chronic renal disease, and her Society of Thoracic Surgeons risk score was 14.3%. A BAV was thought to be useful to determine whether TAVR would alleviate her symptoms. However, she had significant peripheral vascular disease which limited her access sites. The transradial site appeared to be the safest approach, but its small caliber limited the size of the sheath that could be inserted. Therefore, BAV was successfully performed using bilateral 6-Fr radial access, with a reduction of the aortic valve gradient from 40 to 27mmHg. When her symptoms returned several months later, she underwent a TAVR and had a significant improvement in her symptoms and her 6-min walk time doubled 1 month after TAVR. This case illustrates the importance of BAV as a bridge to TAVR in inoperable AS patients. While an open subclavian approach was used for TAVR in this patient, percutaneous axillary, and carotid artery approaches can also be safely performed. These sites can also be used for BAV. In their report, Greason et al showed that careful selection of TAVR patients based on known risk factors significantly increased 1-year survival. BAV may also help to improve outcomes following TAVR, especially in patients with severe COPD and those frail patients with decreased 6-min walk times. BAVwill have an expanded role in the TAVR era and provide more objective data to help Heart Teams decide which inoperable patients will benefit the most from TAVR therapy.