Aortic valvuloplasty.

Balloon aortic valvuloplasty is a palliative treatment for adult patients with aortic stenosis who are not candidates for AVR. BAV can be performed using a single balloon (one balloon, one shaft), multiple balloons (multiple balloons, multiple shafts), or complex balloon configurations (bifoil or trefoil balloons on a single shaft) by the retrograde (femoral or brachial) or antegrade (transseptal) approach. The mechanisms of successful BAV are fracture of calcified nodules, separation of fused commissures, and simple stretching of valve leaflets, leading to increased leaflet mobility and larger orifice dimensions. Clinically, these changes lead to a 50% to 70% decrease in transaortic valve gradient and a 50% to 70% increase in aortic valve area, resulting in immediate improvement in symptoms in most patients. Despite the fact that these beneficial hemodynamic results are achieved with a low incidence of life-threatening complications, the major limitation of BAV is the high incidence of restenosis. About 80% of patients have recurrent symptoms within 2 years of BAV, leading to death of the patient or requiring late AVR or repeat BAV. As a result of the high incidence of restenosis after BAV, elderly patients with aortic stenosis should not be denied the opportunity for AVR solely on the basis of age. BAV may have a role, however, in the following situations: (1) to treat patients in whom AVR is contraindicated for clinical or technical reasons; (2) to treat patients who require urgent noncardiac operations; (3) to clarify the extent of surgery required in patients with aortic stenosis, severe mitral regurgitation, and poor LV function; and (4) to predict the likelihood of successful outcome after AVR in patients with aortic stenosis, low gradients, low cardiac output, and poor LV function.