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[Percutaneous aortic valvuloplasty in the adult. When and why is now useful?]
G Piovaccari1, A Marzocchi, C Marrozzini
1Istituto di Malattie dell'Apparato Cardiovascolare, Università degli Studi di Bologha.
Insights
Percutaneous aortic valvuloplasty offers a palliative option for severe aortic stenosis, particularly in elderly or high-risk patients. However, surgical aortic valve replacement provides better long-term outcomes, with valvuloplasty reserved for select cases.
Area of Science:
- Cardiology
- Interventional Cardiology
Context:
- Percutaneous aortic valvuloplasty (PAV) introduced in 1986 for symptomatic aortic stenosis in elderly patients.
- Mid- to long-term results of PAV have been unsatisfactory due to high restenosis rates (6-12 months).
- Surgical aortic valve replacement (SAVR) shows good long-term results with low perioperative mortality in patients over 70.
Purpose:
- To evaluate the role and indications of PAV in contemporary clinical practice.
- Compare PAV outcomes with SAVR, particularly in high-risk or elderly populations.
- Discuss the utility of PAV as a bridge to surgery or in patients with absolute contraindications.
Summary:
- PAV is a palliative procedure with suboptimal long-term efficacy compared to SAVR.
- SAVR is considered the definitive treatment for aortic stenosis.
- PAV remains indicated for selected patients, including the very old, those with comorbidities, cardiogenic shock, or absolute surgical contraindications.
Impact:
- PAV serves as a crucial intervention for patients unfit for surgery or awaiting definitive treatment.
- Highlights the importance of experienced personnel and specialized centers for safe PAV procedures.
- PAV can improve clinical status in severe aortic stenosis with cardiogenic shock, facilitating later surgical intervention.
Abstract:
Percutaneous aortic valvuloplasty was introduced into clinical practice in 1986 and widely applied in elderly patients with symptomatic aortic stenosis. Nevertheless its results have been unsatisfactory over the mid to long term due to a high incidence of restenosis after 6-12 months. At the same time, patients over 70 years are more frequently undergoing surgical aortic valve replacement with low immediate postoperative mortality and good long term results. Although randomized trials are not available, aortic valve replacement seems to be a definitive therapeutic treatment when compared to the palliative result of aortic percutaneous valvuloplasty. However, since the complication rate of valvuloplasty carried out in cardiological centers with experienced personnel is low, this procedure is still indicated in selected patients. The very old (> 80 years) patients with associated systemic disease, and candidates for major surgery are referred for this procedure. Another indication for aortic valvuloplasty is severe aortic stenosis with cardiogenic shock; in this case, valve dilatation improves clinical status and acts as a "bridge" to surgery, enabling surgical intervention to be carried out at a later date. Nowadays, aortic percutaneous valvuloplasty is a possible alternative to surgical treatment in patients with an absolute surgical contraindication and in those who are in such poor clinical condition that they cannot be immediately referred to surgery. It is also useful for patients requiring urgent non-cardiac surgery (e.g., subjects with gastrointestinal bleeding). We discuss our results with this procedure which concord with those presented in the literature.