Clinical Radiology (1990) 42, 110-113

Aortic Valvoplasty: Comparison of the Techniques and Results of Transeptal and Retrograde Methods R. CROOK, M. WESTON*, R. P. H. WILDE* and G. G. H A R T N E L L *

Departments of Cardiology and *Radiology, Bristol Royal Infirmary, Bristol Balloon aortic valvoplasty is used in some patients with aortic valve stenosis who are unsuitable for aortic valve replacement. Complications associated with the retrograde approach can be avoided using an antegrade approach which has been less widely described. Experience of these two methods is reported and aspects of the differences in technique are emphasized. Aortic valvoplasty was attempted in 21 patients with severe aortic valve stenosis (mean gradient 65 mmHg). A significant reduction in gradient was achieved in 20 (mean reduction 59% transeptal group [four patients], 50% retrograde group [16 patients]) with symptomatic improvement in 18 patients which was maintained at follow-up (mean interval of 5.2 months, range 1-17 months) in 8/15 patients. There were only two significant, resolvable early complications and increases in aortic regurgitation were not seen. There were six late deaths but three patients improved sufficiently to undergo successful aortic valve replacement. Aortic valvoplasty provides good palliation of symptoms. In patients who are unsuitable for the retrograde approach the antegrade, transeptal approach is a satisfactory and effective alternative. Crook, R., Weston, M., Wilde, R.P.H. & Hartnell, G.G. (1990). Clinical Radiology 42, 110-113. Aortic Valvoplasty: Comparison of the Techniques and Results of Transeptal and Retrograde Methods

Balloon aortic valvoplasty was first reported in the treatment of congenital aortic stenosis in 1984 (Lababidi et al., 1984) and in adult calcific aortic stenosis in 1986 (Cribier et al., 1986). Since then there have been many reports of aortic valvoplasty, particularly in patients who are unsuitable for aortic valve surgery (Letac et al., 1988; Safian et al., 1988). The majority of these have reported the results of retrograde, transarterial valvoplasty. There are risks associated with this approach, particularly related to the introduction of the large balloon catheter or sheath into the femoral artery (Block and Palacios, 1987; Letac et al., 1988). It can be difficult to negotiate tortuous iliac arteries (Sohi et al., 1988) or to cross the aortic valve retrogradely and to obtain a stable balloon position (Block and Palacios, 1987). To overcome these problems the technique of transeptal aortic valvoplasty was developed (Grollier et al., 1987; Crick et al., 1987) and this was initially reporte d to cause fewer complications than the retrograde approach. Since then the retrograde technique has been refined and equipment improved but there are very few reports which compare the performance of the two different approaches and even fewer which describe the transeptal approach in detail (Orme et al., 1989). We describe our experience in the use of retrograde and antegrade, transeptal approaches to aortic valvoplasty.

P A T I E N T S AND M E T H O D S Aortic valvoplasty was attempted in 21 patients with severe calcific aortic stenosis who were judged to be unsuitable for surgery. (The indications for valvoplasty Correspondence to: M. Weston, Department of Radiology, Bristol Royal Infirmary, Bristol BS2 8HW. Part of this paper was presented at the Annual Meeting of the Royal College of Radiologists, Liverpool, September 1989.

are summarized in Table 1. Some patients had more than one indication.) The average age was 75.2 years (range 58-89 years). In four patients the transeptal approach was used due either to the presence of peripheral arterial disease, small vessels in a small patient or because on one patient a stable position could not be obtained using the retrograde approach with the balloons and guide wires available. The retrograde approach was used in the remaining 16 patients. All patients gave informed consent prior to valvoplasty which was carried out by one of two consultant radiologists (G.G.H. and R.P.H.W.). The severity of aortic stenosis was assessed by continuous wave Doppler at the time of valvoplasty and at follow-up. Simultaneous aortic and left ventricular pressures were measured at the time of valvoplasty. Balloon size was related to the size of the aortic valve ring measured l~y echocardiography before valvoplasty, usually being just under that size or 23 mm whichever was smaller. All patients were fully anticoagulated with heparin prior to introduction of the dilatation balloon (but after septal puncture in the transeptal group) and dilatation was carried out with continuous E C G and arterial pressure monitoring. An ascending aortogram was performed in all cases before dilatation to exclude severe aortic regurgitation prior to valvoplasty. Limited selective coronary arteriography was carried out to exclude significant proximal coronary artery disease. Retrograde aortic balloon valvoplasty was performed in all cases via a 14 French gauge-valved sheath (Univer" sal Medical Instruments Corp., New York) introduce d via a femoral artery. Prior to introduction of the sheath a selective iliac arteriogram was performed to exclude anY iliac stenosis and to ensure that the artery was large enough to take the sheath. The valve was usually crossed using a Judkin's right coronary catheter and straight guide-wire and then the guide wire was exchanged for a

TRANSEPTAL AND RETROGRADE AORTIC VALVOPLASTY

l 11

Table 1 - Indications for aortic valvoplasty

~vanced age (over 80) poor left ventricular function coronary artery disease Mitralvalvediseaseand pulmonary hypertension Calcifiedmyocardium Chronic renal failure (on dialysis) Chronic obstructive airways disease Severecarotid disease patient refused to undergo surgery

7 12 3 1 1

2 1 1 1

stiff J-backup exchange guide wire (Schneider-Shiley, Zurich). Early experience with conventional exchange guide wires showed that these gave poor balloon stability which made effective dilatation difficult. Current stiffer 'back-up' guide wires produced much better balloon stability and were used in preference to conventional wires. The dilatation balloon was passed over the exchange wire and positioned across the valve (Fig. 1). Balloons were inflated to m a x i m u m size (without measuring the balloon pressure) with dilute contrast medium (diluted to equivalent of 80 mgI/ml to reduce viscosity and allow rapid inflation and deflation). Balloon inflation to maximum diameter was performed rapidly but for only a few seconds on each occasion and repeated, if tolerated, until the gradient had been reduced by at least 50% and preferably to less than 30 m m H g . Antegrade valvoplasty was carried out using a conventional transeptal approach with a modified Brockenburgh needle and a Mullins transeptal catheter and sheath. Various devices were used to cross the mitral valve, depending on the particular problems encountered, including U-shaped pigtail catheters or Swan-Ganz catheters. In crossing the aortic valve J-guide wires, U-pigtail catheters or Swan-Ganz catheters (Fig. 2) were used to turn the corner in the left ventricle and to negotiate the valve. In two patients the route through the heart was

Fig. 1- Retrograde approach. Balloon positioned over aortic valve (largearrow) and guide wire tip curled in left ventricle (small arrow)

Fig. 2 Transeptal approach. Swan Ganz catheter crossingaortic valve to enter ascendingaorta (largearrow). Also monitoring catheters, one in the descending aorta (small arrow) and a Swan Ganz catheter in the pulmonary artery (open arrow)

particularly tortuous and it was not possible to accurately manipulate conventional guide wires through the catheters. In these cases the use of a low friction guide wire (Glide Wire, Terumo Corporation) allowed satisfactory negotiation of the aortic valve. To improve balloon stability once a guide catheter had been passed through the aortic valve, a J-exchange wire was passed through the catheter to the lower descending aorta where it was snared

Fig. 3 Transeptalapproach. Balloon inflatedacross aortic valve(large arrow). Guide wirepassing down descending aorta (smallarrow) so that both ends of the balloon can be stabilized. Monitoring Swan Ganz catheter in pulmonary artery (open arrow)

112

CLINICAL RADIOLOGY

using a l o o p e d guide wire i n t r o d u c e d t h r o u g h an arterial sheath (Crick et al., 1987). This gave c o n t r o l o f b o t h ends o f the guide wire a n d a l l o w e d the easy insertion o f a d i l a t a t i o n b a l l o o n w h i c h c o u l d be k e p t in a stable p o s i t i o n across the a o r t i c valve b y k e e p i n g b o t h ends o f the guide wire t a u t (Fig. 3). It was n o t necessary to dilate the interatrial s e p t u m p r i o r to the insertion o f the v a l v o p l a s t y b a l l o o n . B a l l o o n d i l a t a t i o n s were carried o u t as d e s c r i b e d as above.

Table 3 - Complications

Transeptal approach Asystole requiring resuscitation Retrograde approach Asystole requiring resuscitation Femoral artery pseudoaneurysm Groin haematoma Femoral artery occlusion Transient memory loss

RESULTS A r e d u c t i o n in a o r t i c valve g r a d i e n t was achieved in all patients (20) where the b a l l o o n could be inflated across the aortic valve (Table 2). M e a n g r a d i e n t fell f r o m 65 m m H g (SD 25) to 31 m m H g (SO 15). I n those p a t i e n t s where it was possible to r e c o r d c a r d i a c o u t p u t s there was usually a small d r o p in c a r d i a c o u t p u t , which was never sufficient to a c c o u n t for the d r o p in gradient. In s o m e patients w h o were in c a r d i o g e n i c shock o r w h o b e c a m e h y p o t e n s i v e d u r i n g the p r o c e d u r e increasing doses o f i n o t r o p i c drugs were given. In these patients there were increases in systemic b l o o d pressure. T h e r e were also b l o o d pressure increases in some o t h e r patients n o t receiving i n o t r o p i c agents, after the aortic valve g r a d i e n t h a d been reduced. S a t i s f a c t o r y d i l a t a t i o n c o u l d n o t be achieved in one case due to resistant ventricular a r r h y t h mias d e v e l o p i n g every time a catheter entered the left ventricle ( b o t h t r a n s e p t a l a n d r e t r o g r a d e a p p r o a c h used) a n d in a n o t h e r full inflation c o u l d n o t be achieved due to very r a p i d loss o f a r t e r i a l pressure a n d epileptic fitting every time the b a l l o o n was inflated. There were a n u m b e r o f t r a n s i e n t p r o b l e m s at the time o f the p r o c e d u r e (Table 3) b u t all o f these were c o r r e c t a b l e

a n d there were no long t e r m sequelae f r o m these. One p a t i e n t d e v e l o p e d a f e m o r a l e m b o l u s s h o r t l y after the p r o c e d u r e a n d required e m b o l e c t o m y , subsequently m a k i n g a g o o d recovery. All p a t i e n t s felt dizzy at the time o f d i l a t a t i o n a n d the m a j o r i t y lost consciousness tempor. arily. O n l y one p a t i e n t h a d cerebral d y s f u n c t i o n lasting m o r e t h a n a few m i n u t e s (an episode o f a m n e s i a lasting one d a y in an 88-year-old patient). A t first follow u p (one to f o u r weeks) 18/20 patients r e p o r t e d an i m p r o v e m e n t in s y m p t o m s a n d exercise tolerance. D o p p l e r gradients at this time are summarized in T a b l e 4 . I n one p a t i e n t w h o h a d a satisfactory r e d u c t i o n in g r a d i e n t s i m u l t a n e o u s D o p p l e r a n d catheter g r a d i e n t s at the time o f v a l v o p l a s t y s h o w e d a consider-: able difference ( D o p p l e r g r a d i e n t 100% greater than: c a t h e t e r pressure gradient). A t m o s t recent follow u p three p a t i e n t s h a v e improved e n o u g h to have a o r t i c valve replacement. O f the 15 p a t i e n t s where follow-up d a t a is available ( m e a n interval to follow u p 5.2 m o n t h s ) eight patients are still improved c o m p a r e d with their p r e - v a l v o p l a s t y s y m p t o m s . The: changes in D o p p l e r g r a d i e n t at these a t t e n d a n c e s are s u m m a r i z e d in T a b l e 4. Six patients have died, in eacb~

T a b l e 2 - A o r t i c valve g r a d i e n t b e f o r e a n d after v a l v o p l a s t y

Table 4 - Peak instantaneous

Pt. No.

Pt. No.

Pre (mmHg)

Post (mmHg)

Balloonsize (ram)

Transeptal 1

2 3 3 12 Retrograde 4 5 5 6 7 8 9 10 11 11 13 14 15 16 17 18 19 20 21

30

5

--

D o p p l e r g r a d i e n t s a c r o s s a o r t i c valve

Pre-valvoplasty Post-valvoplasty Late follow up (mmHg) (2 months) (mmHg) (mmHg)

150 65 40 55 (mean 68)

70 35 0 28 (mean 28)

18 15 18 20

Transeptal approach 1 2 3 3 12

22 110 74 35 79

65 80 65 40 75 60 60 60 40 55 65 65 None recorded 50 50 90 110 70 60 (mean 64)

30 30 40 35 45 35 35 25 10 40 30 35 , 25 20 30 50 Unrecorded Failed (mean 32)

20 -20 20 20 20 18 --23 20 20 23 23 20 23 23 23

Retrograde approach 4 5 5 6 7 8 9 10

90 80 60 50 70 50 66 77

11 49 Died at 2 days -26 ----

60

--

11 13

14 15 16 17 18 19 20

80 73 33 56 67 120 155 56

3 72 35 51 64

62 54 44 30 37 78 88 --

Died 2 months 77 Died 3 months AVR 70 60 52 (Died) 54 (Died) 64 59 (Died) Lost to follow Ul 80 --

AVR AVR

AVR, aortic valve replaced The patients from 14 on have not yet come to longer term follow ut

TRANSEPTAL AND RETROGRADE AORTIC VALVOPLASTY case there was very severe left ventricular dysfunction at the time of valvoplasty. M e a n survival from valvoplasty to death was 6.9 months. In two o f these patients an initial improvement (from being in cardiogenic shock and heart failure to being fit e n o u g h to go home) was maintained until sudden death at home. There has been a recurrence of symptoms in three all o f w h o m underwent repeat valvoplasty. One o f these remains improved but the other two have died. One patient developed a small femoral artery aneurysm, which has not required treatment.

DISCUSSION The natural history o f elderly patients with aortic stenosis who refuse or are declined aortic valve surgery is poor. Various studies give mortalities ranging between 91% at 6 m o n t h s and 43% at one year (O'Keefe et al., 1987). This implies the need for an alternative nonsurgical treatment. In the early days o f balloon aortic valvoplasty the transeptal route was p r o m o t e d as the safer m e t h o d but since that time improvements in balloon, sheath and guide wire designs have improved the performance o f the retrograde route so that this is now usually the preferred route. Our experience suggests that in spite o f these developments the transeptal a p p r o a c h has its advantages and can be used safely when the retrograde a p p r o a c h is unsatisfactory. In its short history aortic valvoplasty has generated a large amount o f controversy (Beekman, 1987; Levine and McKay, 1989). Some have p r o m o t e d valvoplasty as a safe effective m e t h o d o f relieving aortic stenosis with continuing improvement (Safian et al., 1988) and as a possible direct alternative to valve replacement (Cribier et al., 1988). Others have suggested that it is o f little use and is at :best only a t e m p o r a r y measure (Grollier et al., 1988; Sprigings et al., 1988). There have also been doubts about its safety (Dash, 1987). A l t h o u g h the reduction in valve gradients m a y be only temporary, as occurred with some of our patients the return o f pre-dilatation gradients as measured by D o p p l e r does not necessarily correlate with the return o f symptoms. There are reservations a b o u t the use of continuous wave D o p p l e r in the follow up o f postvalvoplasty patients ( N i h o y a n n o p o u l o s et al., 1988) as it takes no account o f changes in cardiac output. It has been suggested that the effects o f valvoplasty m a y be due to a more complex effect on aortic flow and left ventricular function than can be detected by measurement o f valve gradients alone (Ferguson et al., 1989). We adopted a relatively conservative a p p r o a c h to patient selection and included a large p r o p o r t i o n o f very sick patients. In spite o f this, aortic valvoplasty p r o d u c e d a significant i m p r o v e m e n t in valve gradient, at least in the short term, and perhaps m o r e importantly a sustained improvement in symptoms, even when there was evidence °frestenosis. Using the appropriate approach, in particular using the transeptal a p p r o a c h in patients where the retrograde a p p r o a c h could be hazardous, aortic balloon Valvoplasty can be performed with a low risk o f serious COmplications. Even very sick patients in cardiogenic Shock and severe heart failure m a y respond sufficiently to

1 13

go home, where before if valve replacement was not possible the o u t c o m e was likely to be early death. Some m a y improve sufficiently to be considered for aortic valve replacement. There is no d o u b t that the effect o f aortic balloon valvoplasty in increasing valve area m a y be only temporary in a significant p r o p o r t i o n o f patients but in spite o f this the majority o f patients have a worthwhile and sustained improvement in s y m p t o m s which makes the risks o f valvoplasty worthwhile. REFERENCES

Acar, J, Vahanian, A, Slama, M, Cormier, B, Michel, PL, Luxereau, Pet al. (1988). Treatment of calcified aortic stenosis: surgery or percutaneous aortic valvoplasty. European Heart Journal, 9, 163 168. Beekman, RH (1987). Percutaneous balloon valvoplasty: Long-term studies are needed. Journal of the American College Cardiology, 9, 732-733. Block, PC & Palacios, IF (1987). Comparison of hemodynamic results of anterograde versus retrograde percutaneous batloon aortic valvoplasty. American Journal of Cardiology, 60, 659 662. Cribier, A, Savin, T, Saondi, N, Rocha, P, Beriand, J & Letac B (1988). Percutaneous transluminal valvulopasty of acquired aortic stenosis in elderly patients. An alternative to valve replacement. Lancet, i, 63-67. Crick, JCP, I~avies, GJ, Impallomeni, M & Oakley, CM (1987). A transeptal aortic valvoplasty. British Heart Journal, 57, 585-586. Dash, H (1987). Have balloon, will travel: Expanded indications for nonoperative intravascular balloon dilation. Journalofthe American College of Cardiology, 9, 387. Ferguson, J J, Bush, HS & Riuli, EP (1989). Doppler echocardiographic assessment of the effect of balloon aortic valvoplasty on left ventricular systolic function. American Heart Journal, 117, 18 24. Grollier, G, Commeau, P, Agostini, D, Durand, C, Foucault, JP & Potier, JC (1987). Anterograde percutaneous transeptal valvuloplasty in a case of severe calcific aortic stenosis. European Heart Journal, 8, 190-193. Grollier, G, Commeau, P, Sesboue, B, Huret, B, Potier, JC & Foucault, JP (1988). Short-term clinical and haemodynamic assessment of balloon aortic valvoplasty in 30 elderly patients. Discrepancy between immediate and eight-day haemodynamic values. European Heart Journal, 9, 155-162. Lababidi, Z, Wu, JR & Walls, JT (1984). Percutaneous balloon aortic valvoplasty: results in 23 patients. American Journal of Cardiology, 53, 194-197. Letac, B, Cibier, A, Koning, R & Bellefleur, J-P (1988). Results of percutaneous transluminal valvuloplasty in 218 adults with valvular aortic stenosis. American Journal of Cardiology, 62, 598-605. Levine, M & McKay, RG (1989). Percutaneous balloon valve dilatation. British Medical Journal, 298, 620-621. Nihoyannopoulos, P, Crick, JCP, Karatasakis, G & Oakley, CM (1988). Value of Doppler echocardiography in balloon dilatation of aortic stenosis. British Heart Journal, 59, 118-119. O'Keefe, JH, Vlietstra, RE, Bailey, KR & Holmes, DR (1987). Natural history of candidates for Balloon Aortic Valvuloplasty. Mayo Clinic Proceedings, 62, 986-991. Orme, EC, Wray, RB, Barry, WH, Krueger, SK & Mason, JW (1989). Comparison of three techniques for percutaneous aortic valvoplasty of aortic stenosis in adults. American Heart Journal, 117, 11 17. Safian, RD, Berman, AD, Diver D J, McKay, LL, Come, PC, Riley, MF et al. (1988). Balloon aortic valvoplasty in 170 consecutive patients. New England Journal Medicine, 319, 125-130. Safian, RD, Warren, SE, Berman, AD, Diver, DJ, McKay, LL, Come, PC et al. (1988). Improvement in symptoms and left ventricular performance in patients with aortic stenosis and depressed left ventricular ejection fraction. Circulation, 78, 1181-1191. Sohi, GS, Coto, H & Joseph, A (1988). Percutaneous aortic valvulopasty. Journal of the Kentucky Medical Association, 86, 124-128. Sprigings, DC, Jackson, G, Chambers , JB, Monaghan, MJ, Thomas, SD, Meany, TB et al. (1988). Balloon dilatation of the aortic valve for inoperable aortic stenosis. British Medical Journal, 297, 1007 1011.