The treatment of aortic stenosis: is valvuloplasty ever an alternative to surgery?

The desire to extend the principle of balloon angioplasty to cardiac valve disease is understandable and commendable. Aortic valvuloplasty is associated, however, with an excessive complication rate, as reported by the Mansfield Scientific Aortic Valvuloplasty Registry (20.5% overall, including a 4.9% death rate within 24 hours and an additional 2.6% rate within 7 days for a 7.5% 1-week mortality). In contrast, the operative mortality for aortic valve replacement now ranges from 3%-5%, with perioperative complications far less than the one in five associated with valvuloplasty. Even if the two procedures had equivalent morbidity and mortality rates, the high incidence of restenosis (30%-60% range at 6 months) for the balloon technique precludes its widespread use for aortic stenosis. Despite the poor mid- and long-term results for balloon valvuloplasty, the procedure may have limited application in some clinical situations. Indeed, there are patients with concomitant systemic illnesses or advanced age ( greater than 80 years) who would not be good surgical candidates. In particular, valvular balloon dilation may be useful in bridging a seriously ill patient to a condition more favorable for replacement therapy. With few exceptions, however, valve replacement remains the gold standard for treatment of adult aortic stenosis.