Balloon aortic valvuloplasty

Since the description by Lababidi in 1983 of balloon aortic valvuloplasty, it has been used extensively by several groups of workers for relief of valvar aortic stenosis of moderate to severe degree. The indications for the procedure are peak-to-peak gradients ≥ 50 mmHg with symptoms or ECG changes or a gradient of ≥ 70 mmHg irrespective of the symptoms and ECG changes. One or more balloon catheters are placed across the aortic valve, over an extra-stiff guidewire and balloon inflated, producing aortic valvuloplasty. The recommended balloon: annulus ratio is 0.8:1.0. Immediate reduction of peak-to-peak gradient along with a fall of left ventricular peak systolic and end-diastolic pressures occurs. Rarely, significant aortic insufficiency, particularly in the neonate, may develop. At intermediate-term follow-up, catheter-measured peak-to-peak gradients and Doppler-measured peak instantaneous gradients remain low for the group as a whole. However, nearly one-quarter of the patients may develop restenosis, defined as peak-to-peak gradient ≥ 50 mmHg. The restenosis is successfully treated with surgical or repeat balloon valvotomy. Predictors of restenosis were age ≤ 3 years and an immediate postvalvuloplasty aortic valve gradient ≥ 30 mmHg. Comparison with surgical results is difficult, but overall, the balloon therapy appears to carry less morbidity. Long-term follow-up data are scanty. The limited data suggest low Doppler peak instantaneous gradients, minimal additional restenosis beyond what was observed at intermediate-term follow-up, and progression of aortic insufficiency in nearly one-quarter of patients. Event-free rates are 76% and 60%, respectively, at 5 and 10 years following initial balloon valvuloplasty. Based on immediate and intermediate-term follow-up data, balloon aortic valvuloplasty appears to produce reasonably good results, avoiding/postponing the need for surgical intervention. The late follow-up data are of some concern in that significant aortic insufficiency with left ventricular dilatation may develop, and some require surgical intervention. Prospective studies on larger groups of children and careful comparison with long-term follow-up surgical data may be necessary to make a definitive recommendation that balloon aortic valvuloplasty is the therapeutic procedure of choice.