Temporizing Balloon Aortic Valvuloplasty Before Transcatheter Aortic Valve Replacement in Decompensated Severe Aortic...

Temporizing balloon aortic valvuloplasty (BAV) may be utilized in the management of decompensated severe aortic stenosis. BAV is occasionally used as a bridge to eventual transcatheter aortic valve replacement (TAVR). We sought to evaluate the outcomes of urgent inpatient TAVR versus BAV followed by TAVR (BAVTAV). The United States Medicare database was used to evaluate all beneficiaries undergoing TAVR (n = 227,145) or BAV (n = 16,643) from 2018 to 2022. Patients were stratified into 3 cohorts: urgent inpatient TAVR without BAV, urgent BAV followed by inpatient TAVR (urgent BAVTAV), and urgent BAV followed by elective outpatient TAVR (elective BAVTAV). To adjust for selection bias, doubly robust risk adjustment was performed using inverse probability weighting and multilevel regression to assess peri-procedural and 5-year outcomes. A total of 23,762 patients underwent urgent TAVR without BAV, while 4,404 patients received BAVTAV (1,503 urgent and 2,901 elective). Inpatient mortality of urgent TAVR, urgent BAVTAV, and elective BAVTAV was 3.0%, 5.3%, and 1.5%, respectively, with a similar association for acute stroke (2.1% vs 2.7% vs 2.0%) and new pacemaker implantation (8.5% vs 8.5% vs 6.0%). After risk adjustment, elective BAVTAV was associated with lower index mortality (odds ratios 0.61, p = 0.011), stroke (odds ratios 0.55, p < 0.0001), and longitudinal mortality (hazard ratio 0.67, p < 0.001) compared with urgent TAVR. Urgent BAVTAV was associated with a higher index and longitudinal mortality. In conclusion, among Medicare beneficiaries with acutely decompensated severe aortic stenosis, temporizing BAV as a bridge to future outpatient elective TAVR appears to be a viable treatment strategy when felt to be medically possible.