CASE REPORT
Balloon aortic valvuloplasty as a bridge to
aortic valve replacement in a patient with
severe calcific aortic stenosis B.M. Swinkels, W. Jaarsma, L. Rdlik-van Wely, HA. van Swieten, J.M.P.G. Ernst, H.W.M. Plokker
This case report describes a patient with severe calcific aortic stenosis who was initially considered inoperable because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved to such an extent that subsequent aortic valve replacement was considered possible and eventually proved to be successful. Balloon aortic valvuloplasty has value as a potential bridge to aortic valve replacement when the risks for surgery are considered to be too high. (NethHeartJ 2003;11:129-31.) Key words: balloon aortic valvuloplasty, aortic valve replacement, aortic stenosis
Balloon aortic valvuloplasty for severe calcific aortic stenosis was introduced in 1986.1 Because of a high incidence ofprocedural complications and a high short-term and long-term restenosis rate, the procedure did not turn out to be an alternative for aortic valve replacement in patients who are candidates for surgery.2-6 For this reason, balloon aortic valvuloplasty has been abandoned in many centres. The purpose of this case report is to stress the value of balloon aortic valvuloplasty as a bridge to conventional aortic valve replacement. We present a patient with severe calcific aortic stenosis who had initially been turned down for B.M. Swinkels. W. Jaarsma. Department of Cardiology, St. Antonius Hospital, P0 Box 2500, 3430 EM Nieuwegein. L Relk-van Wely. Department of Cardiology, Bemhoven Hospital, P0 Box 5460, DA Veghel. HA. van Sweten. J.M.P.G. Enist. H.W.M. Plokker. Department of Cardiothoracic Surgery, St. Antonius Hospital, P0 Box 2500, 3430 EM Nieuwegein. Address for correspondence: H.W.M. Plokker. E-mail: [email protected]
Nctherlands Heart Journal, Volume 11, Number 3, March 2003
surgery because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved sufficiently to enable subsequent aortic valve replacement to be carried out successfully.
Case report A 59-year-old man was admitted to Bemhoven Hospital with grade III angina pectoris, according to the Canadian Cardiovascular Society Functional Classification, and pulmonary oedema. Echocardiography revealed critical calcific aortic stenosis with a valve area of 0.7 cm,2 moderate (grade 2/4) aortic regurgitation and a dilated left ventricle with severely impaired systolic function. Cardiac catheterisation confirmed a very poor left ventricular function (ejection fraction 9%) and severe pulmonary hypertension (pulmonary artery pressures of 89/47 mmHg). Coronary arteriography showed a proximally occluded right coronary artery and a significant stenosis in the middle part of the left anterior descending coronary artery. After initial stabilisation by diuretics, the pulmonary artery pressures turned out to be irreversibly elevated despite dopamine and nitroglycerin. The patient was referred to St. Antonius Hospital for aortic valve replacement, but initially rejected for surgery because of the very poor left ventricular function in combination with fixed pulmonary hypertension (besides two-vessel coronary artery disease). Alternatively, balloon aortic valvuloplasty was offered as a 'last resort' procedure in an attempt to improve the left ventricular function and pulmonary hypertension, after which conventional aortic valve replacement could be reconsidered. For this strategy, the patient was again referred to St. Antonius Hospital. By then, he was comfortable only at rest. On physical examination he measured 1.73 m and weighed 76 kg. His blood pressure was 100/60 mmHg and the pulse was regular at a rate of 68 beats/min. The jugular venous pressure appeared normal. Auscultation showed a systolic crescendodecrescendo murmur grade 3/6, best heard in the aortic area and radiating to the carotid arteries, and a diminished second heart sound. Lungs were clear to 129
Balloon aortic valvuloplasty as a bridge to aortic valve replacement in a patient with severe calcific aortic stenosis
an increase in aortic regurgitation. The left ventricular function did not show an evident increase in ejection fraction (from 9 to 10%), but via a Swan Ganz catheter a small decrease in pulmonary artery pressures was noted (from 70/37 to 60/40 mmHg). Because the clinical and haemodynamic status of the patient had improved to some extent, he was now accepted for surgery, which took place eighteen days after balloon aortic valvuloplasty. During the operation, the calcific aortic valve was replaced with a 25-mm Carbomedics prosthetic valve and the proximal occlusion in the right coronary artery was bypassed with a venous graft. The postoperative course was uncomplicated and the patient was transferred back to Bernhoven hospital. There, he was discharged in a relatively improved condition on the 14th postoperative day. Four months later, his condition had further improved (New York Heart Association Functional Classification II) and echocardiography showed a raised left ventricular ejection fraction of 22% with normalised pulmonary artery pressures. Figure 1. Balloon aortic valvulplasty of the stenotic aortic valve (left anterior oblique view). The balloon has been fully inflated. Annulus cakifications can be seen (arrow).
auscultation. Bilaterally, mild ankle oedema was found. The electrocardiogram demonstrated sinus rhythm and signs of severe left ventricular hypertrophy. On the chest x-ray the heart was enlarged (cardiothoracic ratio 58%) and the pulmonary vascularity was increased. Low-dose dobutamine echocardiography demonstrated a limited contractile reserve of the nearly akinetic left ventricle, with only a mild increase in mean valve pressure gradient (from 25 to 38 mmHg) and no increase in aortic valve area (0.7 cm2). Via a Swan Ganz catheter pulmonary artery pressures of 70/37 mmHg were measured, which could not be lowered with dopamine and nitroglycerin. Balloon aortic valvuloplasty was then undertaken. This procedure was performed using the retrograde technique employing the femoral artery for vascular access. A pigtail catheter was advanced into the left ventricle over a guidewire, revealing a peak-to-peak aortic valve pressure gradient of 40 mmHg. The pigtail catheter was exchanged for a 23 x 45 mm BALT balloon catheter, which was positioned across the aortic valve and inflated twice (figure 1). After removing the balloon, a postvalvuloplasty peak-to-peak aortic valve pressure gradient of 25 mmHg was measured. The systolic pulmonary artery pressure, recorded by right heart catheterisation, had decreased from 87 mmHg directly preceding the valvuloplasty to 68 mmHg directly afterwards. Subsequently, a PTCA procedure of the mid left anterior descending coronary artery stenosis was carried out. Four days later, echocardiography revealed an increase in the aortic valve area (from 0.7 to 1.3 cm2) without 130
Dlscussion In patients with severe calcific aortic stenosis who are candidates for surgery, aortic valve replacement remains the treatment of choice, because the long-term outcome after surgery is excellent with a survival rate approaching that of an age-matched control population without aortic stenosis.7 This case report demonstrates that balloon aortic valvuloplasty can serve as a bridge to conventional aortic valve replacement when the patient is initially considered inoperable. Reasons for being considered inoperable can be advanced age, poor left ventricular function, severe pulmonary hypertension and other severe cardiovascular or noncardiac diseases.8" In these circumstances, we think there are three options. First, to perform no intervention at all. This will inevitably lead to a fatal outcome. The second option is to perform balloon aortic valvuloplasty without intending to replace the aortic valve at a later stage. In that case, the patient will have the same limited lifespan because the mortality rate after balloon aortic valvuloplasty for severe aortic stenosis seems to be similar to the natural history of the severe aortic stenosis itself.'2 The third option is balloon aortic valvuloplasty as a bridge to conventional aortic valve replacement. As we and others'3 have shown, a modest increase in aortic valve area after balloon aortic valvuloplasty can be sufficient to improve the haemodynamic condition. Aortic valve replacement can then be undertaken with a lower surgical risk and with subsequently improved long-term outcome.
Conclusin Balloon aortic valvuloplasty as a bridge to aortic valve replacement is a serious option for patients with severe calcific aortic stenosis who are considered to be at too high a risk for surgery. Although the procedural risks for both balloon aortic valvuloplasty and aortic valve Netherlands Heart Joumal, Volume I1, Number 3, March 2003
Balloon aortic valvuloplasty as a bridge to aortic valve replacement in a patient with severe calcific aortic stenosis
replacement are substantial,'4"15 the long-term results after aortic valve replacement are excellent. So, this strategy of balloon aortic valvuloplasty with a view to conventional aortic valve replacement may be of help to these very ill patients who have relatively little to lose and a lot to win. v
8
9
10
Rees 1
2
3 4
5
6 7
Cribier A, Saoudi N, Berland J, Savin T, Rocha P, Letac B. Percutaneous transluminal valvuloplasty ofacquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet 1986;1:63-7. Bemard Y, Etievent J, Mourand J, Anguenot T, Schiele F, Guseibat M, et al. Long-term results of percutaneous aortic valvuloplasty compared with aortic valve replacement in patients more than 75 years old. JAm Coll Cardiol 1992;20:796-801. Lieberman EB, Wllson JS, Harrison JK, Pieper KS, Kisslo KB, Lowe J, et al. Aortic valve replacement in adults after balloon aortic valvuloplasty. Circulation 1994;90:II-205-8. Kuntz RE, Tosteson ANA, Berman AD, Goldman L, Gordon PC, Leonard BM, et al. Predictors of event-free survival after balloon aortic valvuloplasty. NEnglJMed 1991;325:17-23. Lieberman EB, Bashore TM, Hermilier JB, Wilson JS, Pieper KS, Keeler GP, et al. Balloon aortic valvuloplasty in adults: failure of procedure to improve long-term survival. J Am Coll Cardiol 1995;26:1522-8. Eltchaninoff H, Cribier A, Tron C, Anselme F, Koning R, Soyer R, et al. Balloon aortic valvuloplasty in elderly patients at high risk for surgery, or inoperable. EurHeartJ 1995;16:1079-84. Soyer R, Bouchart F, Bessou JP, Redonnet M, Mouton-Schleifer D, Derumeaux G, et al. Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis. EurJCardiothorac Surg 1996;10:977-82.
Neands Heart Jounal, Volume 11, Numbsr 3, March 2003
11
12
13 14
15
NHLBI Balloon Valvuloplasty Registry Participants. Percutaneous balloon aortic valvuloplasty: acute and 30-day fbllow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry. Circulation 1991;84:2383-97. Holmes DR, Nishimura RA, Reeder GS. In-hospital mortality after balloon aortic valvuloplasty: frequency and associated factors. JAm CoU Cardiol 1991;17:189-92. Moreno PR, Jang IK, Newell JB, Block PC, Palacios IF. The role of percutaneous aortic valvuloplasty in patients with cardiogenic shock and critical aortic stenosis. JAm CoU Cardiol 1994:23:10715. O'Neill WW, for the Mansfield Scientific Aortic Valvuloplasty Registry Investigators. Predictors of long-term survival after percutaneous aortic valvuloplasty: report of the Mansfield Scientific Baloon Aortic Valvuloplasty Registry. JAm CoU Cardiol 1991;17: 193-8. Otto CM, Mickel MC, Kennedy JW, Alderman EL, Bashore TM, Block PC, et al. Three-year outcome after balloon aortic valvuloplasty: insights into prognosis ofvalvular aortic stenosis. Circulation 1994;89:642-50. Smedira NG, Ports TA, Merrick SH, Rankin JS. Balloon aortic valvuloplasty as a bridge to aortic valve replacement in critically ill patients. Ann Thorac Sur,g 1993;55:914-6. McKay RG, for the Mansfield Scientific Aortic Valvuloplasty Registry Investigators. The Mansfield Scientific Aortic Valvuloplasty Registry: overview of acute hemodynamic results and procedural complications. JAm CoU Cardiol 1991;17:485-91. Johnson RG, Dhillon JS, Thurer RL, Safian RD, Weintraub RM. Aortic valve operation after percutaneous aortic balloon valvuloplasty. Ann Thorac Surg 1990;49:740-5.
131
Balloon aortic valvuloplasty as a bridge to
aortic valve replacement in a patient with
severe calcific aortic stenosis B.M. Swinkels, W. Jaarsma, L. Rdlik-van Wely, HA. van Swieten, J.M.P.G. Ernst, H.W.M. Plokker
This case report describes a patient with severe calcific aortic stenosis who was initially considered inoperable because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved to such an extent that subsequent aortic valve replacement was considered possible and eventually proved to be successful. Balloon aortic valvuloplasty has value as a potential bridge to aortic valve replacement when the risks for surgery are considered to be too high. (NethHeartJ 2003;11:129-31.) Key words: balloon aortic valvuloplasty, aortic valve replacement, aortic stenosis
Balloon aortic valvuloplasty for severe calcific aortic stenosis was introduced in 1986.1 Because of a high incidence ofprocedural complications and a high short-term and long-term restenosis rate, the procedure did not turn out to be an alternative for aortic valve replacement in patients who are candidates for surgery.2-6 For this reason, balloon aortic valvuloplasty has been abandoned in many centres. The purpose of this case report is to stress the value of balloon aortic valvuloplasty as a bridge to conventional aortic valve replacement. We present a patient with severe calcific aortic stenosis who had initially been turned down for B.M. Swinkels. W. Jaarsma. Department of Cardiology, St. Antonius Hospital, P0 Box 2500, 3430 EM Nieuwegein. L Relk-van Wely. Department of Cardiology, Bemhoven Hospital, P0 Box 5460, DA Veghel. HA. van Sweten. J.M.P.G. Enist. H.W.M. Plokker. Department of Cardiothoracic Surgery, St. Antonius Hospital, P0 Box 2500, 3430 EM Nieuwegein. Address for correspondence: H.W.M. Plokker. E-mail: [email protected]
Nctherlands Heart Journal, Volume 11, Number 3, March 2003
surgery because of a very poor left ventricular function and severe pulmonary hypertension. After balloon aortic valvuloplasty, the clinical and haemodynamic status of the patient improved sufficiently to enable subsequent aortic valve replacement to be carried out successfully.
Case report A 59-year-old man was admitted to Bemhoven Hospital with grade III angina pectoris, according to the Canadian Cardiovascular Society Functional Classification, and pulmonary oedema. Echocardiography revealed critical calcific aortic stenosis with a valve area of 0.7 cm,2 moderate (grade 2/4) aortic regurgitation and a dilated left ventricle with severely impaired systolic function. Cardiac catheterisation confirmed a very poor left ventricular function (ejection fraction 9%) and severe pulmonary hypertension (pulmonary artery pressures of 89/47 mmHg). Coronary arteriography showed a proximally occluded right coronary artery and a significant stenosis in the middle part of the left anterior descending coronary artery. After initial stabilisation by diuretics, the pulmonary artery pressures turned out to be irreversibly elevated despite dopamine and nitroglycerin. The patient was referred to St. Antonius Hospital for aortic valve replacement, but initially rejected for surgery because of the very poor left ventricular function in combination with fixed pulmonary hypertension (besides two-vessel coronary artery disease). Alternatively, balloon aortic valvuloplasty was offered as a 'last resort' procedure in an attempt to improve the left ventricular function and pulmonary hypertension, after which conventional aortic valve replacement could be reconsidered. For this strategy, the patient was again referred to St. Antonius Hospital. By then, he was comfortable only at rest. On physical examination he measured 1.73 m and weighed 76 kg. His blood pressure was 100/60 mmHg and the pulse was regular at a rate of 68 beats/min. The jugular venous pressure appeared normal. Auscultation showed a systolic crescendodecrescendo murmur grade 3/6, best heard in the aortic area and radiating to the carotid arteries, and a diminished second heart sound. Lungs were clear to 129
Balloon aortic valvuloplasty as a bridge to aortic valve replacement in a patient with severe calcific aortic stenosis
an increase in aortic regurgitation. The left ventricular function did not show an evident increase in ejection fraction (from 9 to 10%), but via a Swan Ganz catheter a small decrease in pulmonary artery pressures was noted (from 70/37 to 60/40 mmHg). Because the clinical and haemodynamic status of the patient had improved to some extent, he was now accepted for surgery, which took place eighteen days after balloon aortic valvuloplasty. During the operation, the calcific aortic valve was replaced with a 25-mm Carbomedics prosthetic valve and the proximal occlusion in the right coronary artery was bypassed with a venous graft. The postoperative course was uncomplicated and the patient was transferred back to Bernhoven hospital. There, he was discharged in a relatively improved condition on the 14th postoperative day. Four months later, his condition had further improved (New York Heart Association Functional Classification II) and echocardiography showed a raised left ventricular ejection fraction of 22% with normalised pulmonary artery pressures. Figure 1. Balloon aortic valvulplasty of the stenotic aortic valve (left anterior oblique view). The balloon has been fully inflated. Annulus cakifications can be seen (arrow).
auscultation. Bilaterally, mild ankle oedema was found. The electrocardiogram demonstrated sinus rhythm and signs of severe left ventricular hypertrophy. On the chest x-ray the heart was enlarged (cardiothoracic ratio 58%) and the pulmonary vascularity was increased. Low-dose dobutamine echocardiography demonstrated a limited contractile reserve of the nearly akinetic left ventricle, with only a mild increase in mean valve pressure gradient (from 25 to 38 mmHg) and no increase in aortic valve area (0.7 cm2). Via a Swan Ganz catheter pulmonary artery pressures of 70/37 mmHg were measured, which could not be lowered with dopamine and nitroglycerin. Balloon aortic valvuloplasty was then undertaken. This procedure was performed using the retrograde technique employing the femoral artery for vascular access. A pigtail catheter was advanced into the left ventricle over a guidewire, revealing a peak-to-peak aortic valve pressure gradient of 40 mmHg. The pigtail catheter was exchanged for a 23 x 45 mm BALT balloon catheter, which was positioned across the aortic valve and inflated twice (figure 1). After removing the balloon, a postvalvuloplasty peak-to-peak aortic valve pressure gradient of 25 mmHg was measured. The systolic pulmonary artery pressure, recorded by right heart catheterisation, had decreased from 87 mmHg directly preceding the valvuloplasty to 68 mmHg directly afterwards. Subsequently, a PTCA procedure of the mid left anterior descending coronary artery stenosis was carried out. Four days later, echocardiography revealed an increase in the aortic valve area (from 0.7 to 1.3 cm2) without 130
Dlscussion In patients with severe calcific aortic stenosis who are candidates for surgery, aortic valve replacement remains the treatment of choice, because the long-term outcome after surgery is excellent with a survival rate approaching that of an age-matched control population without aortic stenosis.7 This case report demonstrates that balloon aortic valvuloplasty can serve as a bridge to conventional aortic valve replacement when the patient is initially considered inoperable. Reasons for being considered inoperable can be advanced age, poor left ventricular function, severe pulmonary hypertension and other severe cardiovascular or noncardiac diseases.8" In these circumstances, we think there are three options. First, to perform no intervention at all. This will inevitably lead to a fatal outcome. The second option is to perform balloon aortic valvuloplasty without intending to replace the aortic valve at a later stage. In that case, the patient will have the same limited lifespan because the mortality rate after balloon aortic valvuloplasty for severe aortic stenosis seems to be similar to the natural history of the severe aortic stenosis itself.'2 The third option is balloon aortic valvuloplasty as a bridge to conventional aortic valve replacement. As we and others'3 have shown, a modest increase in aortic valve area after balloon aortic valvuloplasty can be sufficient to improve the haemodynamic condition. Aortic valve replacement can then be undertaken with a lower surgical risk and with subsequently improved long-term outcome.
Conclusin Balloon aortic valvuloplasty as a bridge to aortic valve replacement is a serious option for patients with severe calcific aortic stenosis who are considered to be at too high a risk for surgery. Although the procedural risks for both balloon aortic valvuloplasty and aortic valve Netherlands Heart Joumal, Volume I1, Number 3, March 2003
Balloon aortic valvuloplasty as a bridge to aortic valve replacement in a patient with severe calcific aortic stenosis
replacement are substantial,'4"15 the long-term results after aortic valve replacement are excellent. So, this strategy of balloon aortic valvuloplasty with a view to conventional aortic valve replacement may be of help to these very ill patients who have relatively little to lose and a lot to win. v
8
9
10
Rees 1
2
3 4
5
6 7
Cribier A, Saoudi N, Berland J, Savin T, Rocha P, Letac B. Percutaneous transluminal valvuloplasty ofacquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet 1986;1:63-7. Bemard Y, Etievent J, Mourand J, Anguenot T, Schiele F, Guseibat M, et al. Long-term results of percutaneous aortic valvuloplasty compared with aortic valve replacement in patients more than 75 years old. JAm Coll Cardiol 1992;20:796-801. Lieberman EB, Wllson JS, Harrison JK, Pieper KS, Kisslo KB, Lowe J, et al. Aortic valve replacement in adults after balloon aortic valvuloplasty. Circulation 1994;90:II-205-8. Kuntz RE, Tosteson ANA, Berman AD, Goldman L, Gordon PC, Leonard BM, et al. Predictors of event-free survival after balloon aortic valvuloplasty. NEnglJMed 1991;325:17-23. Lieberman EB, Bashore TM, Hermilier JB, Wilson JS, Pieper KS, Keeler GP, et al. Balloon aortic valvuloplasty in adults: failure of procedure to improve long-term survival. J Am Coll Cardiol 1995;26:1522-8. Eltchaninoff H, Cribier A, Tron C, Anselme F, Koning R, Soyer R, et al. Balloon aortic valvuloplasty in elderly patients at high risk for surgery, or inoperable. EurHeartJ 1995;16:1079-84. Soyer R, Bouchart F, Bessou JP, Redonnet M, Mouton-Schleifer D, Derumeaux G, et al. Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis. EurJCardiothorac Surg 1996;10:977-82.
Neands Heart Jounal, Volume 11, Numbsr 3, March 2003
11
12
13 14
15
NHLBI Balloon Valvuloplasty Registry Participants. Percutaneous balloon aortic valvuloplasty: acute and 30-day fbllow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry. Circulation 1991;84:2383-97. Holmes DR, Nishimura RA, Reeder GS. In-hospital mortality after balloon aortic valvuloplasty: frequency and associated factors. JAm CoU Cardiol 1991;17:189-92. Moreno PR, Jang IK, Newell JB, Block PC, Palacios IF. The role of percutaneous aortic valvuloplasty in patients with cardiogenic shock and critical aortic stenosis. JAm CoU Cardiol 1994:23:10715. O'Neill WW, for the Mansfield Scientific Aortic Valvuloplasty Registry Investigators. Predictors of long-term survival after percutaneous aortic valvuloplasty: report of the Mansfield Scientific Baloon Aortic Valvuloplasty Registry. JAm CoU Cardiol 1991;17: 193-8. Otto CM, Mickel MC, Kennedy JW, Alderman EL, Bashore TM, Block PC, et al. Three-year outcome after balloon aortic valvuloplasty: insights into prognosis ofvalvular aortic stenosis. Circulation 1994;89:642-50. Smedira NG, Ports TA, Merrick SH, Rankin JS. Balloon aortic valvuloplasty as a bridge to aortic valve replacement in critically ill patients. Ann Thorac Sur,g 1993;55:914-6. McKay RG, for the Mansfield Scientific Aortic Valvuloplasty Registry Investigators. The Mansfield Scientific Aortic Valvuloplasty Registry: overview of acute hemodynamic results and procedural complications. JAm CoU Cardiol 1991;17:485-91. Johnson RG, Dhillon JS, Thurer RL, Safian RD, Weintraub RM. Aortic valve operation after percutaneous aortic balloon valvuloplasty. Ann Thorac Surg 1990;49:740-5.
131
