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HélèneEltchaninoffHôpitalCharlesNicolle-ROUENTheRoleofBalloonAorticValvuloplastyinTAVRandasStand-AloneTherapyMoscow20121985BalloonAorticValvuloplastywasproposedasapalliativeprocedureforinoperablepatientswithASTHELANCET,JANUARY11,1986RouenSept198572y-oldfemale,72y-oldfemale,F.I.M.:20mmBalloonUntilrecentlyaortiquesavantposedevalveRestenosisrate80%ESCGuidelines2007:RestrictiveIndications•AsabridgetoAVRinhighriskPtswithunstablehemodynamicstatus•InsymptomaticPtsbeforeurgentnon-cardiacsurgery•AsapalliativetreatmentifAVRiscontra-indicatedIIblevelC2002AneweraforBAVSince2002ObservedonbothsidesoftheAtlantic1)ArterialandveinousintroducersBolusd’HéparineIV(3-5000UI)aprèslaposedesintroducteurs2)Heparin:70UI/KgTechniqueofBAVLeftAmplatz2catheterLeftAmplatz2catheterAorticvalvecrossingAorticvalvecrossingStraight0.035wireStraight0.035wireLAO40°LAO40°3)Longextra-stiffCook0.035guidewire4)PacingleadintheRVTemporarypacingleadforTemporarypacingleadforRightVentricularPacing220/minRightVentricularPacing220/min5)Balloonsizeselection-BALT:10Fcompatible-BALT:10Fcompatible-Z-MED:12-14Fcompatible-Z-MED:12-14FcompatibleDyedilution:15%Dyedilution:15%Balloonsizes•2-3inflations•Increaseballoonsizeifresultisnotsufficient(20-23-25mm)6)BallooninflationGoal:-Meangradient20mmHg-and/orAVA0,9cm²FemoralarteryclosureAngiosealAngioseal8F8FProglideouProstarProglideouProstarReverseheparinattheendoftheprocedureBalloons:20,23,25mmBalloons:20,23,25mmVentricularpacingIn2012,BAVisasimpleprocedureIntroducers:10FIntroducers:10FPreclose/AngiosealclosurePreclose/AngiosealclosureLocalanesthesiaLocalanesthesiaShorthospitalization(48h)Shorthospitalization(48h)5%95%AlternativetechniqueThetranseptalapproachprepostAVA(cm²)0.66±0.241.10±0.39Meangradient(mmHg)45.4±19.320.9±11.3Hemodynamicresults:Hemodynamicresults:RouenseriesRouenseriesFurutaetal.AHA2009Furutaetal.AHA2009ProceduralcomplicationRouenseries,321PtsProceduraldeath4(1.2%)Nonfatalcomplications:Surgicalvascularcomplications6(1.8%)StrokeorTIA6(1.8%)Massiveaorticregurgitation5(1.5%)PermanentAVblock2(0.6%)AHA2010ComplicationsComplications(Severe)(Severe)MansfieldRegistry(1986-1988)n=492Rouen(2005-2008)n=321PerproceduraldeathPerproceduraldeath4,9%2.1%StrokeStroke2.2%1.9%TamponadeTamponade2,2%0%ARGrade3-4ARGrade3-41,1%1.5%A-VBlockA-VBlock1.2%0.9%VascularcomplicationVascularcomplication11%0.9%22.6%7.3%TotalBejaretal-ACC2010ComplicationsofBAVarerare262PtsF-up:181jBen-Dor,Pichardetal-JACC2011;3:1150-6Mid-termOutcomeafterBAValoneCurrentIndicationsofBAVintheTAVIEra1)AsapartoftheTAVIprocedure2)AsabridgetoTAVI/AVR3)Asaselectiontoolindifficultdecisions4)AsatooltoselectTAVIsize5)Beforeurgentextra-cardiacsurgery6)Asapalliativeproceduretoalleviatesymptoms1inflationunderrapidpacingwithastableballoonandwithoutwaist1)AspartoftheTAVIprocedure:Pre-dilatation2)AsabridgetoTAVI/AVRfortemporarycontra-indications•Unstablehemodynamiquestatus(cardiogenicshock,refractoryheartfailure)•ToimproveLVfunctionpriortoTAVI/AVREuroIntervention2011MAINRESULTSOFTHESTUDY•InPtswithassociatedrespiratoryinsufficiency•IncaseofverydepressedLVEFfunction•InPtswithcognitivedeterioration(dementia?;lowoutput?)3)BAVasadiagnostictesttoevaluatesymptoms/LVEFimprovementindifficultclinicalsituations4)BAVasatooltoselecttheTAVIsizeinborderlinecases:UseofmanualaortographyduringBAVNoLEAKwith23-mmballoon23-mmEdwardsconfirmedB.BORZ-EuroPCR2011NoLEAKwith23-mmballoon23-mmEdwardsconfirmedLEAKwith23-mmballoon26-mmEdwardsconfirmedConclusion•BAVisasimpleprocedureassociatedwithrarecomplicationswithimprovedtechniqueandtechnology•IndicationsofBAVhavechangedoverthelastyearswithadominantroleofBAVasabridgetoAVR/TAVIinPtswithtemporarycontra-indicationsordifficultdecisions•BAValonecouldbeusefultoallevaitesymptomsandhastoberepeatedMedicalRedoTAVIAVRAVR(N=31)2514134TAVI(N=54)321582Redo(N=28)221261Medical(N=210)822172Survival5.1%20.9%42.6%70%monthsROUENseries–323Patients2005-2009ACC2011TranscatheterAorticValveImplantationforAorticStenosisinPatientsWhoCannotUndergoSurgery.MartinB.Leonetal.TheNewEnglandJournalofMedicine.September2010PARTNERUS–CohortB50.7%30.7%∆at1year20%NNT=5pts