Balloon Rupture during Pre-Dilation for Transcatheter Aortic Valve Replacement in Patients with Bicuspid Aortic Valve: Classification, Treatment Strategies, and Prevention
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Balloon rupture during transcatheter aortic valve replacement (TAVR) is a rare but serious complication. We present two cases of balloon rupture in patients with severe aortic stenosis and type 0 bicuspid aortic valve. Three-dimensional models based on pre-procedure cardiac CT angiography were used to post hoc investigate these cases. The models revealed asymmetrical distribution of calcifications with sharp spiked features in bicuspid aortic valves. The narrow and calcified orifice resulted in uneven force distribution on the expanded balloon, leading to balloon rupture. Furthermore, we reviewed the classification and causes of balloon rupture and summarized avoidance methods and treatment options. Accurate pre-procedural anatomy evaluation and computer modeling are crucial for planning and managing TAVR procedures. Further investigation through computer simulation is needed to determine the appropriate balloon size and inflation locations to provide the reference of preparation pre-procedure.Keywords:
Aortic valvuloplasty
Valve replacement
Bicuspid valve
Balloon dilation
Bicuspid valve
Raphe
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Surgical aortic valvuloplasty (SAV) and balloon aortic valvuloplasty (BAV) are two main treatments for children with isolated congenital aortic stenosis (CAS). We aim to compare the two procedures' midterm outcomes, including valve function, survival, reintervention, and replacement. From January 2004 to January 2021, children with isolated CAS undergoing SAV (n = 40) and BAD (n = 49) at our institution were included in this study. Patients were also categorized into subgroups based on the aortic leaflet number(Tricuspid = 53, Bicuspid = 36) to compare the two procedures' outcomes. Clinical and echocardiogram data were analyzed to identify risk factors for suboptimal outcomes and reintervention. Postoperative peak aortic gradient (PAG) and PAG at follow-up in the SAV group were lower compared with the BAV group (p < 0.001, p = 0.001, respectively). There was no difference in moderate or severe AR in the SAV group compared with the BAV group before discharge (5.0% vs 12.2%, p = 0.287) and at the last follow-up (30.0% vs 32.7%, p = 0.822). There were no early death but three late deaths (SAV = 2, BAV = 1). Kaplan-Meier estimated survivals were 86.3% and 97.8% in SAV and BAV groups respectively at 10 years (p = 0.54). There was no significant difference in freedom from reintervention (p = 0.22). For patients with bicuspid aortic valve morphology, SAV achieved higher freedom from reintervention (p = 0.011) and replacement (p = 0.019). Multivariate analysis indicated that residual PAG was a risk factor for reintervention (p = 0.045). SAV and BAV achieved excellent survival and freedom from reintervention in patients with isolated CAS. SAV performed better in PAG reduction and maintenance. For patients with bicuspid AoV morphology, SAV was the preferred choice.
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Hereditary factors may have a part to play in the development of bicuspid aortic valve. This report concerns a pair of identical twins, probably monozygotic, who required aortic valve replacement as a result of aortic stenosis occurring in bicuspid aortic valves. This supports the contention that there may be a genetic influence in the development of bicuspid aortic valve, though environmental factors may be of greater importance.
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The bicuspid aortic valve is the most frequent congenital cardiac malformation; it may be isolated or associated with other congenital heart disease. The present investigation consists of a study of bicuspid aortic valves in 1022 heart specimens belonging to the anatomical collection of the Institute of Pathological Anatomy of the University of Padua. A bicuspid aortic valve was observed in 95 specimens. It occurred as an isolated congenital cardiac defect in 28 cases, seven of which had spontaneous laceration of the aortic valve (aortic dissection). It was associated with other congenital cardiac malformations in 67 out of the remaining 994 specimens (6.7%), 41 of which (61.2%) showed obstruction of the aortic arch. The frequency of bicuspid aortic valve in specimens with complete transposition of great arteries was only 1%. Bicuspid aortic valve was particularly frequent in association with ventricular septal defect and was significantly more frequent in cases with (51.1%) than in cases without (20.5%) aortic arch obstruction (p < 0.001). There was no significant relationship between the occurrence of bicuspid aortic valves and left ventricular outflow tract obstructions or mitral valve malformations. The morphology of the pulmonary valve was also examined. Concurrence of a bicuspid aortic and pulmonary valve was detected in 11 specimens, five of these had trisomy-18. Our findings cast doubt on the assumption that altered fetal blood flow through the aortic valve may be the main factor producing the bicuspid condition. Indeed, they rather support the hypothesis that most bicuspid aortic valves are expressions of a developmental complex that affects the aortic arch and the wall of the ascending aorta as well as the aorta valve.
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Ventricular outflow tract
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For infants with valvar aortic stenosis, balloon aortic valvuloplasty has supplanted surgical valvotomy as the initial treatment of choice at most institutions. Technological innovations have resulted in further miniaturization of balloon dilation catheters, allowing this procedure to be performed through smaller sheath sizes. Currently, the Tyshak-Mini balloon dilation catheter (B. Braun Medical) allows passage of up to an 8 mm dilation balloon catheter through a 3 Fr hemostatic sheath. The efficacy of this system for the treatment of valvar aortic stenosis in infants less than 6 months of age was evaluated in 20 patients undergoing 22 procedures. Mean age at the time of intervention was 26 +/- 46 days. Mean transvalvar gradient was 76 +/- 22 mm Hg prior to balloon dilation. Following balloon valvuloplasty, residual gradient was 26 +/- 12 mm Hg, reflecting a mean change in peak-to-peak gradient of 49 +/- 19 mm Hg. Postintervention increase in aortic insufficiency was one grade or less in 19/22 procedures, two grades in 2 procedures, and three grades in 1 procedure. There were no significant vascular complications reported immediately following the procedure. Repeat valvuloplasty was performed in three patients in which the 3 Fr system was used in two patients. The 3 Fr system for balloon aortic valvuloplasty in infants less than 6 months of age is effective and safe.
Aortic valvuloplasty
Balloon dilation
Balloon valvuloplasty
Balloon catheter
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Bicuspid valve
Aortic valvuloplasty
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The study aim was to investigate the immediate and long-term results of balloon aortic valvuloplasty (BAV) in young patients (aged ≤20 years) with congenital bicuspid aortic valve presenting with severe aortic stenosis.The study involved a single tertiary care center-based retrospective data analysis of immediate and long-term outcomes in patients following balloon valvuloplasty between 2000 and 2011. A total of 92 young patients (mean age 12.7 years; 95% CI 8.3-16.7 years) with aortic stenosis due to congenital bicuspid aortic valve and who underwent BAV were studied.The mean follow up period was 5.7 ± 1.3 years. Intervention resulted in successful BAV (≥50% reduction in baseline gradient) in 79 patients (85.9%; group A) and partially successful BAV (<50% reduction in baseline gradient) in eight patients (8.7%; group B). BAV failed in five patients (5.4%; group C). The mean left ventricular systolic pressure was decreased from 155.6 mmHg (95% CI 132.7-186.3 mmHg) to 100.9 mmHg (95% CI 82.1-119.6 mmHg; p <0.001), and the mean aortic valve gradient from 40.7 mmHg (95% CI 25.12-56.22 mmHg) to 17.2 mmHg (95% CI 15.83- 21.23 mmHg; p <0.001). Mean changes in aortic valve area and mean gradient were significantly different between successful BAV groups (A and B) and the failed BAV group (p = 0.001). Different grades of aortic regurgitation were noted in 32 patients (34.78%) after BAV (severe regurgitation in 2.18%). A post hoc analysis showed sustained gradient reductions at one- and five-year follow up investigations (p <0.05). The need for surgery was much lower in the successful BAV groups.The success of BAV in bicuspid aortic valve stenosis in younger patients was approximately 85%. Although 10% of patients developed re-stenosis and required surgical intervention, the majority did well during the follow up period. It was concluded that BAV is a viable option in adolescents and young children with bicuspid aortic valve without severe calcification.
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Bicuspid valve
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