Balloon Aortic Valvuloplasty in the Transcatheter Aortic Valve Replacement Era

Anirudh Kumar, MD; David Paniagua, MD; Ravi S. Hira, MD; Mahboob Alam, MD; Ali E. Denktas, MD; Hani Jneid, MD


J Invasive Cardiol. 2016;28(8):341-348. 

In This Article

Abstract and Introduction


Background. The introduction of transcatheter aortic valve replacement (TAVR) has renewed interest in balloon aortic valvuloplasty (BAV) for severe aortic stenosis (AS). It is unclear whether technical advances and increased operator experience associated with TAVR development have resulted in improved BAV outcomes. We performed a systematic review encompassing all published BAV studies and examined the evolution in indications, outcomes, and complications of BAV procedures since its inception.

Methods. A literature search from 1986 through June 2013 was conducted for all studies reporting BAV outcomes. Studies with <50 BAV procedures were excluded. BAV outcomes and complications were compared in studies enrolling patients in the early/pre-TAVR and contemporary/TAVR periods (before vs after 2005).

Results. Twenty-seven studies representing 4123 patients were included. In the contemporary era, BAV was performed as a bridge to TAVR in 23.4% of patients. Significant and comparable improvement in transaortic valvular gradients, aortic valve area, and cardiac output following BAV were observed in both time periods. There was, however, a significant reduction in procedural death (1.5% vs 2.9%; P<.01), in-hospital mortality (4.6% vs 8.5%; P<.001), and major vascular complications (4.0% vs 10.2%; P<.001) associated with BAV procedures in the contemporary/TAVR era.

Conclusion. BAV is increasingly used as a bridge to TAVR, continues to impart significant hemodynamic improvement in patients with severe AS, and has an improved safety profile in the contemporary era.


Aortic stenosis (AS) is currently the most common valvular heart disease in the elderly, with a prevalence of moderate to severe AS in 2.8% of adults 75 years or older.[1] Without treatment, AS is rapidly progressive with an average survival as low as 1–3 years after symptom onset.[2–5] In the United States, only ~40% of patients with severe AS will undergo either surgical or transcatheter aortic valve replacement (TAVR).[1] Surgical aortic valve replacement (SAVR) has been the gold-standard treatment for symptomatic patients for decades and is associated with low operative mortality in patients without significant comorbidities.[6–10] In current clinical practice, many patients present with numerous medical comorbidities and advanced age, which make them prohibitive or high risk for SAVR.[3] With an aging population, the prevalence of degenerative AS will continue to impose an increasing burden on the health-care system, requiring alternative forms of treatment for high-risk patients.[11]

Percutaneous balloon aortic valvuloplasty (BAV), first clinically introduced by Cribier in 1986, was initially proposed as a therapeutic option for non-operative patients with severe AS.[12] Although immediate postprocedural hemodynamic parameters demonstrated modest but consistent improvement, high procedural mortality rate, high complication rate, and limited impact on long-term survival driven by temporary relief of the stenosis tempered the initial enthusiasm for the procedure.[13–15] As a result, previous American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommended BAV as a possibly-reasonable therapy (class IIb) to be used as a bridge to surgery in hemodynamically unstable AS patients who are at high risk for SAVR, or for palliation in AS patients in whom AVR cannot be performed because of serious comorbidities.[16]

TAVR has emerged as a definitive therapy for patients with severe AS who are at prohibitive or high surgical risk.[3,17–18] With the advent of TAVR, the development of novel devices, and technical improvements, a resurgence in the use of BAV has been observed. In the current report, we have performed a systematic literature review and pooled analyses of all published BAV studies aiming to examine changes in the indications, outcomes, and complications of BAV in the early/pre-TAVR and contemporary/TAVR eras.