Balloon Valvuloplasty


Article Author:
Oscar Perez


Article Editor:
Arun Kanmanthareddy


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
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Hassam Zulfiqar
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John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/15/2019 10:45:43 PM

Introduction

Balloon valvuloplasty is a cardiac intervention to open up a stenotic or stiffed heart valves (e.g., aortic or mitral) using a catheter with a balloon on the tip. It is also known as balloon valvotomy. It is a less invasive procedure because it is done by inserting a catheter into the blood vessel from groin percutaneously rather than valve replacement with cardiothoracic surgical or other open methods. Balloon valvulotomy has several types, depending upon which heart valve is involved for example:

  • Percutaneous balloon tricuspid valvuloplasty
  • Percutaneous balloon pulmonary valvuloplasty
  • Percutaneous balloon mitral valvuloplasty
  • Percutaneous balloon aortic valvuloplasty[1]

Anatomy

The heart is a four-chamber blood-pumping organ in the chest cavity. Blood flows from one chamber to another through valves. The following are the four valve classifications:

  • Tricuspid valve: present between the right atrium and ventricle
  • Pulmonary valve: present between the right ventricle and pulmonary article
  • Mitral valve: a bicuspid valve present between the left atrium and ventricle
  • Aortic valve: present between the left ventricle and ascending aorta

With the ongoing age, any inflammation or infection of the valve or a congenital heart defect causes the leaflets of valves to become stiff and calcified hence causing hindrance in the flow of blood from one chamber to another.[2]

Indications

The balloon valvuloplasty can be used for treating stenosis of tricuspid, pulmonary, mitral, and aortic valves, but in some cases, its potential risks outweigh its potential benefits. The following are the indications of balloon valvuloplasty in different valvular stenosis. 

Tricuspid Valve Stenosis 

The treatment of tricuspid stenosis is a combination of medical and valvular interventions. For patients with severe tricuspid valve stenosis, valve replacement surgery is preferred over balloon valvulotomy as most cases are associated with tricuspid regurgitation, and balloon valvuloplasty can worsen regurgitation. To choose balloon valvuloplasty over tricuspid valve replacement surgery in an isolated, symptomatic, severe tricuspid stenosis with mild to less tricuspid regurgitation, the surgical risk of a patient must be too high and outweigh disadvantages of over benefits of balloon valvuloplasty.

Pulmonary Valve Stenosis

Percutaneous balloon pulmonary valvulotomy (BPV) is preferred in moderate (gradient 40 to 60 mmHg) to severe (greater than 60 mmHg) pulmonary stenosis and it is the first-line treatment of typical dome-shaped valvular pulmonary stenosis in severe stenosis (gradient greater than 60 mmHg). BPV is also the preferred treatment in neonates with critical pulmonary stenosis.

Mitral Valve Stenosis

The percutaneous mitral balloon valvuloplasty is the treatment of choice in patients with mitral valve stenosis who have following features:

  • Severe mitral stenosis
  • Pliable, noncalcified mitral valves
  • Symptomatic
  • The absence of left atrial thrombus
  • The absence of moderate to severe mitral regurgitation
  • Older patients or who are at high risk for surgery

It is primarily performed in patients with rheumatic mitral stenosis. There is a little experience with percutaneous balloon mitral valvuloplasty in congenital mitral stenosis.

Aortic Valve Stenosis

  • Use in calcified aortic stenosis: Use of balloon aortic valvotomy (BAV) is limited in calcified aortic stenosis. The use is generally limited to two settings:
    1. Percutaneous BAV is used as a bridge to surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR) in a severely symptomatic aortic stenosis
    2. For patients with a severely symptomatic aortic stenosis who require an urgent non-cardiac surgery
  • Use in congenital aortic stenosis: Balloon aortic valvotomy (or valvuloplasty, BAV) is a first-line treatment option for children and younger adults with aortic stenosis with the congenital disease without significant valve calcification.[3]

Contraindications

The percutaneous balloon valvuloplasty is contraindicated if in the presence of moderate to severe valvular regurgitation, infective endocarditis, vegetation, tumor, or irreversible noncardiac disease that is severely limiting life. [4]

Preparation

Admit the patient to the hospital a day before the procedure for preparation. A detailed history should be taken especially for cardiac and pulmonary diseases. Questions regarding age, weight, height, previous medical history, and medications including anticoagulants; heart, vascular, liver, kidney, and musculoskeletal disease and any current symptoms; any allergies in the past; complications during previous surgeries or complications of anesthesia in any family member; and social and sexual history should be documented. The patient is not allowed to eat or drink after midnight and should remain nill per oral (NPO) until after the procedure. [4]

Technique

The procedure started with a local anesthetic injection at the site of catheter insertion. Some IV sedative medicines are also given to help the patient relax before the procedure. After identifying the site of insertion just above the vessel in the groin, the doctor inserts an introducer into the vessel which helps with the later introduction of the catheter through the vessel into the heart. Following catheterization, the practitioner begins injecting contrast dye from the IV line to check the exact place of catheter and valve. As he or she approaches the required position, the balloon is inflated, forcing the calcified valve leaflets open. By fracturing the calcified deposits within the leaflets, the inflated balloon relieves the stenosis. After that, the practitioner deflates the balloon and removes the catheter. [5]

Complications

A variety of complications are associated with balloon valvuloplasty. The following are some of the main complications:

  • Bleeding or hematoma formation at the catheter site insertion
  • Infection at the catheter site
  • Vessel damage due to multiple puncturing attempts
  • Contrast dye allergy
  • Arrhythmia
  • Stroke
  • Valve rupture requiring open heart surgery
  • Ventricular rupture 
  • Valve regurgitation[6]

Clinical Significance

Balloon valvuloplasty is a less invasive than open-heart valve replacement, but it is not an alternative to valve replacements.

Studies comparing ballon tricuspid valvuloplasty to surgical tricuspid valve replacement are not available, so in most of the cases, tricuspid valve surgery is preferred. However, in high-risk surgical cases or with moderate to severe valvular regurgitation associated with tricuspid stenosis, balloon tricuspid valvuloplasty can be performed.

Pulmonary stenosis is a common congenital heart disease characterized by the right ventricular outflow obstruction. The clinical significance in treating pulmonary stenosis in children mainly depends on the severity of obstruction. Mild pulmonary stenosis (gradient <greater than 0 mmHg) does not require intervention. In moderate pulmonary stenosis (gradient 40 to 60 mmHg) and severe pulmonary stenosis (gradient greater than 60 mmHg), balloon pulmonary valvuloplasty is preferred.

The outcome of clinical trials on the clinical significance of percutaneous balloon mitral valvuloplasty compared to open and closed surgical commissurotomy was that percutaneous mitral balloon valvuloplasty was good or better than surgery in patients who were candidates for valvotomy.

Percutaneous balloon aortic valvuloplasty has a limited role in the treatment of calcific aortic stenosis. BAV is first-line therapy in children and younger adults with aortic stenosis due to congenital disease (generally due to bicuspid commissural fusion) without significant valve calcification.[3]


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Balloon Valvuloplasty - Questions

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In which clinical situation is the treatment of aortic stenosis with percutaneous balloon aortic valvuloplasty appropriate?



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A 75-year old in the intensive care unit with multiple organ dysfunction has been diagnosed with severe aortic valve stenosis. The surgeon does not recommend open-heart surgery but suggests balloon valvoplasty. What is the key reason why percutaneous aortic valvoplasty is considered a palliative procedure?



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Which of the following statements is false concerning balloon aortic valvuloplasty?



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A 17-year-old man comes with the complaint of shortness of breath with exertion for two months. The shortness of breath was gradual and aggravates with exercise and relieves with rest. The patient denies any dizziness, racing of his heart, chest pain, cough, fever, allergies and occupational exposure. His temperature is 98.8 F, respiration rate is 16 per min, heart rate is 72/min, and blood pressure is 130/75 mmHg. Chest auscultation reveals a harsh systolic murmur at right second intercostal space with radiation along the carotid arteries. An S4 is also present. Which of the following is a preferable method of management?



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A 17-year-old patient complains of groin pain in postop after percutaneous balloon aortic valvuloplasty for the congenital bicuspid aortic valve. His pulse was 90/min 1 hour after the procedure but now has increased to 110/min. The blood pressure drops to 95/65 mmHg. What should be expected?



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Balloon Valvuloplasty - References

References

Mahfouz RA,Elawady W,Goda M,Moustafa T, Redo Scoring for Prediction of Success of Redo-Percutaneous Balloon Mitral Valvuloplasty in Patients with Mitral Restenosis. The Journal of heart valve disease. 2017 Sep     [PubMed]
Pozzoli A,Zuber M,Reisman M,Maisano F,Taramasso M, Comparative Anatomy of Mitral and Tricuspid Valve: What Can the Interventionlist Learn From the Surgeon. Frontiers in cardiovascular medicine. 2018     [PubMed]
Ford TJ,Nguyen K,Brassil J,Kushwaha V,Friedman D,Allan R,Pitney M,Jepson N, Balloon Aortic Valvuloplasty in the Transcatheter Valve Era: Single Centre Indications and Early Safety Data in a High Risk Population. Heart, lung     [PubMed]
Francisco AR,Nobre Menezes M,Carrilho Ferreira P,Jorge C,Silva D,Infante de Oliveira E,Pinto FJ,Canas da Silva P, Balloon aortic valvuloplasty in the transcatheter aortic valve implantation era: A single-center registry. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology. 2017 Apr     [PubMed]
Shivaraju A,Thilo C,Sawlani N,Ott I,Schunkert H,von Scheidt W,Kastrati A,Kasel AM, Aortic Valve Predilatation with a Small Balloon, without Rapid Pacing, prior to Transfemoral Transcatheter Aortic Valve Replacement. BioMed research international. 2018     [PubMed]
Petit CJ,Qureshi AM,Glatz AC,Kelleman MS,McCracken CE,Ligon RA,Mozumdar N,Whiteside W,Khan A,Goldstein BH, Technical factors are associated with complications and repeat intervention in neonates undergoing transcatheter right ventricular decompression for pulmonary atresia and intact ventricular septum: results from the congenital catheterisation research collaborative. Cardiology in the young. 2018 Aug     [PubMed]

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