Two years' experience of percutaneous balloon valvuloplasty in aortic stenosis
Cribier, A.; Letac, B.
Herz 13(2): 110-118
1988
ISSN/ISBN: 0340-9937 PMID: 3378720 Document Number: 318821
To provide an overview of our experience with percutaneous balloon valvuloplasty in aortic stenosis, the results obtained in 218 patients have been analyzed. During the two years of its use, the technique of the procedure has been subsequently modified with increasing balloon diameters, initially 15 mm, 18 mm and then 20 mm; currently, a balloon diameter of up to 23 mm or even two balloons may be used. Accordingly, in our last 70 patients, significantly larger valve orifice areas have been achieved. The mean postinterventional valve orifice area was 1.06 cm2. In 73% of the patients valve orifice area was 0.9 cm2 or greater, in 60% 1 cm2 or more. In consideration of the high prevalence of elderly, severely-ill patients in our series, the in-hospital mortality of 4.5% (ten of 218 patients) was relatively low. Nonfatal complications included stroke in three, tamponade in three, and myocardial infarction in one patient with severe coronary artery disease. In 25 patients (13%) there were bleeding complications at the site of vascular puncture, nine of which required surgical revision. Valvuloplasty usually did not result in worsening of aortic incompetence and, consequently, up to grade II regurgitation need not be considered a contraindication. Follow-up data was obtained at an average of eight months (three to 18 months) after the procedure in the first 148 patients. During this period, 24 patients had died, 19 of whom were in functional class IV and all of whom had impaired left ventricular function and residual severe aortic stenosis after the procedure. Most of the survivors were stable and had marked clinical improvement. Of the 87 patients in functional class III or IV prior to the procedure, after eight months of follow-up, only 14 were in these subsets. Chest pain disappeared or was markedly improved in 50 of the 67 patients who presented with angina pectoris before valvuloplasty. No patient had recurrence of a syncopal attack. The best indicator for the presence of restenosis is recurrence of symptoms and this proved to be the case in each of eleven patients in whom repeat hemodynamic assessment was carried out after an average of six months due to renewed symptomatic status. In 41 further patients who underwent scheduled follow-up catheterization, ten patients (25%) were found to have restenosis (defined as as 50% loss of the postvalvuloplasty gain in aortic valve area). However, this group, primarily including patients from our early experience, demonstrated by more current criteria clearly insufficient valvuloplasty results; the majority had less than a 50% increase in valve area as compared to the 50 to 100% increase almost invariably achieved more recently. With respect to improved skill rendered by experience, changes in definition of success and restenosis and improvements in instrumentation, the longterm results, in particular, of procedures currently performed are not known. Valvuloplasty would certainly seem indicated for patients who are not suitable candidates for surgery. Further studies will be of value to determine the place of valvuloplasty in patients below the age of 70 years who would otherwise be capable of undergoing surgery.