Perkutana balonska aortna valvuloplastika kot možnost paliativnega zdravljenja za inoperabilne bolnike?
Percutaneous balloon aortic valvuloplasty: palliative
treatment for inoperable patients?
Avtor / Author	Klemen Dovč1, Andrej Markota1, Vojko Kanič1,3, Mirko Bombek1,3,
Gregor Prosen2,3
Ustanova / Institute	1Univerzitetni klinični center Maribor, Klinika za interno medicino, Maribor, Slovenija;
2Zdravstveni dom Adolfa Drolca, Maribor, Slovenija, 3Univerza v Mariboru, Medicinska fakulteta, Katedra za interno medicino, Maribor, Slovenija,
1University Medical Center Maribor, Clinic for Internal Medicine, Maribor, Slovenia; 2Adolf Drolc Health Center Maribor, Maribor, Slovenia, 3University of Maribor, Faculty of Medicine, Department of Internal medicine, Maribor, Slovenia
Ključne besede:
aortna stenoza, balonska aortna valvuloplastika, akutno srčno popuščanje
Key words:
Aortic stenosis, balloon aortic valvuloplasty, acute heart failure
Članek prispel / Received
09.09.2011
Članek sprejet / Accepted
28.10.2011
Naslov za dopisovanje / Correspondence
Andrej Markota, Univerzitetni klinični center Maribor, Klinika za interno medicino, Ljubljanska 5, Sl-2000 Maribor, Slovenija Telefon +386 51311519
E-pošta: andrejmarkota@hotmail.com
Izvleček
Namen. V razvitih državah se zaradi staranja prebivalstva povečuje število starostnikov s hudo aortno stenozo. Tveganje za zaplete je pri kirurški zamenjavi aortne zaklopke, ki je standarden način zdravljenja, pri tej skupini bolnikov visoko. Za zdravljenje omenjene skupine starostnikov razvijajo perkutane načine zdravljenja, kot sta perkutana balonska aortna valvuloplastika in perkutana vstavitev aortne zaklopke. Prikaz primera V prispevku je opisan primer 84-letne bolnice z le-vostransko hemiparezo po možganski kapi in generalizirano aterosklerozo. Sprejeta je bila zaradi pljučnega edema, zdravljenje z neinvazivno ventilacijo in inotropi pa ni bilo uspešno. Perkutana balonska aortna valvuloplastika je bila opravljena 6 ur po sprejemu. Takoj po posegu se je bolni-čino stanje izboljšalo. Po 25 dneh bol-
Abstract
Purpose: The number of elderly patients with severe aortic stenosis and comorbidities is increasing in the aging populations of "developed" countries. Unacceptably high perioperative mortality and morbidity makes the decision to undertake surgical aortic valve replacement in this group of patients difficult and unlikely. Development of less invasive procedures such as balloon aortic valvuloplasty and transcatheter aortic valve replacement is emerging as another treatment option.
Case report A 84-year-old female with previous left-sided hemiparesis after stroke and severe aortic stenosis presented with pulmonary edema to our institution. Non-invasive ventilation and inotropic support were unsuccessful. Balloon aortic valvuloplasty was done as as emergency procedure and she improved immediately. She
nišničnega zdravljenja smo jo odpustili v domsko varstvo. Zaključek Perkutana balonska aortna valvuloplastika je dodatna možnost zdravljenja bolnikov z aortno stenozo in visokim tveganjem za zaplete ob kirurškem zdravljenju. Balonska dilatacija aortne zaklopke ima lahko vlogo pali-ativnega posega ali premostitvenega posega do kirurške ali perkutane zamenjave aortne zaklopke.
was discharged after 25 days of inhospital treatment. She died 8 weeks later of unrelated reasons (infected decubitus and sepsis).
Conclusion Balloon aortic valvoluplasty might be used as temporary and interim therapeutical options for patients with severe aortic stenosis and acute left ventricular failure who have unacceptably high risks when aortic valve replacement or emergency transcatheter aortic valve implantation is considered. Balloon aortic valvuloplasty may be used as a bridge to both procedures.
INTRODUCTION
Aortic stenosis (AS) is the most common valvular disease in "developed" countries. Once patients develop symptoms, life expectancy without surgery is <3 years (1, 2). The "gold standard" treatment is surgical aortic valve replacement (AVR). Surgery in elderly, comorbid patients often carries unacceptable risks of surgical morbidity and mortality (2-4). In these patients, transcatheter aortic valve implantation (TAVI) is emerging as another option (5). We report a case of a 84-year-old female with generalized atherosclerosis and severe AS who presented with acute pulmonary edema. Conservative therapy was unsuccessful. We undertook emergency balloon aortic valvuloplasty (BAV), after which the patient improved and was discharged after 25 days of in-hospital treatment.
CASE REPORT
An 84-year-old female with known severe AS (transvalvular gradient, 81 mmHg; aortic-valve area, 0.6 cm2) was admitted to hospital because of pulmonary edema. She had known threevessel coronary artery disease, peripheral arterial disease, an abdominal aortic aneurism, and had suffered ischaemic stroke with subsequent left-sided hemiparesis in the week before hospital admission. In the previous year she had been admited to our institution thrice because of left ventricular failure. She had been referred to a cardiosurgery team in s previous hospitalization but
was classified "inoperable" because of high surgical risk (at that time: Euroscore calculated risk was 15; logistic, 55.45%). BAV was not considered in previous hospitalizations because of appropriate response to medical therapy.
Upon hospital admission she was dyspneic with respiratory rate of 25/min and peripheral oxygen saturation of 92% upon 100% oxygen and non-invasive ventilation. Widespread inspiratory crackles were present over the lungs. Laboratory tests revealed elevated levels of brain natriuretic peptide (1,201 pg/L) as well as mildly elevated creatinine (156 pmol/L) and troponin I levels (0.08 pg/L). These were, in the absence of angina and ischemic changes on electrocardiography, attributed to acute heart failure. Signs of congestive heart failure were also visible on chest radiography. Non-invasive ventilation, which was initiated in the pre-hospital setting, was continued. Inotropic support (dobutamine) was instituted. However, all attempts to stabilize the patient failed. Six hours after hospital admission we undertook emergency rescue BAV. Both femoral arteries and right femoral vein were canulated. First, coronary angiography was done and revealed three-vessel disease. We decided against percutaneous revascularization in the acute setting. The aortic valve was crossed with a guidewire and a temporary pacing lead positioned in the right ventricle via the right femoral vein. Three dilations of the aortic valve were undertaken with a 20 x 4 mm balloon under rapid ventricular pacing (200/min). The transvalvular gradient was reduced to 33 mmHg
as measured invasively (Figure 1). One hour after the procedure we weaned the patient off non-invasive ventilation; dobutamine was discontinued the next day. She was discharged after 25 days of hospital treatment. TAVI and percutaneous revascularization were being considered as delayed procedures, but she died 8 weeks later of unrelated reasons (infected decubitus and sepsis).
DISCUSSION
BAV was first described in 1986 (1). In the short-term, good hemodynamic and clinical responses were
observed. A high prevalence of restenosis, high risk of procedural mortality and morbidity, and a poor prevalence of survival have contributed to a decline in the use of BAV. AVR remains to this day the gold-standard treatment of AS (1-3). In some cases, however, AVR is not appropriate for patients who decline surgery or in cases where predicted surgical mortality and morbidity is too high (4).
BAV can be employed as a palliative procedure in elderly, highly comorbid patients (5, 6). However, BAV itself is not without risk. Intra-procedural death can be expected in 2% of patients, stroke in 2-5%;
occlusion of coronary arteries in 2%; and procedure-related severe aortic regurgitation, tamponade and need for permanent pacemaker implantation in 1% each. Vascular complications occur in 7-10% of patients (6, 7, 8). The most common complication is post-procedural rise in creatinine levels (10-15%), whereas the requirement for hemodialysis is rare (1%). Serious procedure-related adverse events can be expected in 15-30% of patients (6, 7). In spite of the risk of complications, good short-term hemodynamic responses can be expected, with an increase in aortic valve area (AVA) of «0.3 cm2 and a fall in the mean and peak gradient of «30 mmHg. An increase in cardiac output and decline in pulmonary artery and left-ventricular end-diastolic pressure can also be expected. The prognosis remains poor after BAV alone, with 6-month mortality reaching 50% (6, 7, 8). Risk scores are being developed that identify patients at high risk of BAV-related mortality (9). In our case, concomitant acute heart failure and generalized atherosclerosis (three-vessel coronary artery disease, carotid atherosclerosis, abdominal
aortic aneurism and peripheral arterial disease) made the procedure extremely risky (upon admission: the Euroscore-calculated risk was 17; logistic 71.74%) (5). There were no procedure-related complications. The patient improved immediately after the procedure. Weaning from non-invasive ventilation was possible within 1 h; dobutamine infusion was discontinued the next day. Echocardiography upon hospital discharge revealed AVA 1.0 cm2 (improvement of 0.4 cm2) and a gradient of 42 mmHg (improvement of 50 mmHg).
CONCLUSION
The number of elderly patients with AS will continue to increase in the future. Concomitant cardiac and non-cardiac diseases make AVR inapropriate for some patients because of high surgical risks. Medical therapy is not successful. BAV can be used in these patients as a bridge to AVR or TAVI. In the emergency setting, BAV might also be used as paliative treatment for selected patients.
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