Balloon Aortic Valvuloplasty

Equipment
  • Sheaths
    • Definitive BAV: Single arterial access
      • Micropuncture access kit, 6, 7.5, 8 Fr sheaths. 10/11/12/13 Fr sheaths (depending on balloon size)
    • Possible BAV: Single arterial access
      • Micropuncture access kit, 6, and 7.5 Fr sheaths.
    • Catheters
      • Swan-Ganz
      • 5Fr Amplatz right 2 (AR2)
      • 6Fr Judkins left 4 (JL4)
    • Wires
      • 035” Standard J-wire
      • 038” Straight-tip Stiff Terumo GLIDEWIREÒ
      • 035” Amplatz Super StiffTM (3.5 cm flexible tip)/ 0.035” ConfidaTM / 0.035” SAFARI2 Guidewire
    • Balloon
      • Z-MED II-XTM balloon (18-23 mm)
      • TrueTM balloon (20-22 mm)
    • Closure device
      • Perclose x 2 for definitive BAV (1 Perclose for possible BAV)
    • Other equipment and medications
      • Contrast 50 cc, diluted 1:3
      • 3 manifolds
      • Heparin 2000 units prior to crossing the valve and consider additional heparin if difficulty in crossing the valve
      • Atropine or Phenylephrine if needed to maintain an adequate heart rate and blood pressure
      • Temporary venous pacemaker (TVP)
 
Vascular Access
  • Definitive BAV:
    • Single arterial access: 6Fr sheath in common femoral artery (CFA) using micropuncture access technique and upsize to 8 Fr sheath.
    • Place two suture-based closure device (Perclose) in orthogonal positions (referred as Preclose). After Preclose, upsize to 10 Fr sheath.
    • Venous access: Femoral vein with 7.5Fr sheath for hemodynamic assessment using a Swan-Ganz catheter.
  • Possible BAV:
    • Single arterial access: 6Fr sheath in CFA micropuncture access technique
    • Place one suture-based closure device (Perclose) in the same direction as the needle puncture (referred as Preclose). After Preclose, upgrade to an 8Fr sheath
    • Venous access: Femoral vein with 7.5Fr sheath for hemodynamic assessment using a Swan-Ganz catheter.
  • Angiographic views
    • Aortogram: LAO 30o
    • Crossing the valve: LAO 30o
    • Inflation of balloon: RAO 30o
Crossing the aortic valve
  • Catheter manipulation
    • Advance AR2 or AL1 catheter to the aortic root. AL2 can be used for very large aortic root, and AR1 and JR 4 for small root. Occasionally, MP catheter may be required.
    • Once catheter is positioned in the aorta, compare the pressure in the aorta to the femoral sheath side-arm pressure (both transducers need to be zeroed and flushed again). Measure the difference AO-FA gradient between the central aortic pressure and CFA pressure. If the difference is more than 10 mmHg, a double-lumen pigtail should be used.
    • In LAO 30o view, perform a root aortogram and store this image as a reference picture on the second monitor (Figure). Pull the catheter back with a slow but firm clockwise rotation to direct the catheter tip to the center of the valve plane.
    • Cross the aortic valve with a 0.038” Straight-tip Stiff Terumo GLIDEWIREÒ
  • Wire manipulation
    • In the same fluoroscopic view as the reference image, move the guide wire with firm gentle movements in and out of the catheter tip with the right hand, while the left hand torques the catheter to keep in plane the valve orifice.
    • Once the wire crosses the aortic valve, it is advanced to the middle of the LV, and the fluoroscopic view is changed to RAO to see the wire tip.
    • The catheter is then advanced over the guidewire and positioned in mid-ventricular position in RAO 30o
    • Connect the catheter to the manifold system and check the left ventricle-femoral artery gradient (LV-FA). If original femoral pressures were discrepant by more than 10 mmHg with the aortic pressure, then double-lumen pigtail (Langston) catheter is placed with exchange length J wire into ventricle. If the central aortic pressure was greater than the FA pressure, subtract the AO-FA value from the gradient measured across the valve to get the true gradient across the valve. If the central aortic pressure was lesser than the FA pressure, add the AO-FA value from the gradient measured across the valve to get the true gradient across the valve.
    • Use dobutamine for low-gradient, low-flow AS if LVEF is <50% as per protocol
    • If valvuloplasty is appropriate, then Confida/SAFARI wire in LV, through the AR2/Langston catheter.
Balloon Management
  • Balloon sizing:
    • Around 1:0.9 to annulus size.
    • Z-MED II-XTM balloon catheter: 20 mm (11 Fr sheath), 22 mm (12 Fr sheath), 23 mm (13 Fr sheath) and 25 mm (14 Fr sheath).
    • Use the smaller 20 mm balloon if the valve is densely calcified or the aortic annulus is small (<19 mm by echocardiography).
    • In general, we begin with a 22 mm Z-MED II-XTM in most of our cases, we do not use a larger balloon, though a 25 mm balloon can be used if the aortic annulus diameter is larger than 24 mm.
    • True balloon: 20 mm (11Fr sheath) and 22 mm (12 Fr sheath)
    • Pediatric Atlas balloon 20 mm (9 Fr sheath) and Tyshak 22 mm balloon (8Fr sheath).
  • Balloon preparation
    • Flush the balloon through the flush port. Attach the 3-way stopcock to the balloon inflation extension of the catheter. Attach a 60 cc syringe filled with a 40 cc of diluted contrast (1:3) to the straight port of the stopcock. De-air the balloon by pulling negative with a 60 cc syringe. Repeat three to four times to ensure the balloon does not have air and remove air from the syringe as well. Attach another 10 cc balloon filled with contrast/saline (diluted 1:3) to another port.
 Temporary Pacemaker Use
  • Position a balloon tipped temporary pacemaker in the right ventricular apex/posterior wall through the femoral vein after removing the Swan-Ganz catheter and deflate the temporary wire tip balloon to secure the position. The pulse generator has a capability of up to 220 beats/min.
  • Capture is verified prior to balloon inflation (test at least 10-20 beats/min faster than the intrinsic rhythm). Use the pulse generator to pace at 180 beats/min (or above) to decrease systolic blood pressure to 50 mmHg. If BP does not decrease, or 2:1 conduction block is seen, a slower rate may be considered (160 beats/min) (Figure). 
Balloon Inflation
  • While pacing, exert simultaneous forward pressure on the balloon catheter (loaded on the stiff wire). Inflate the balloon via 60 cc syringe and via 10 cc syringe if needed to ensure complete expansion. Look for loss of aortic pressure waveform with balloon inflation and disappearance of waist at valve orifice (Figure). In case the BAV is done as a part of transcatheter valve replacement, a 20 cc aortogram may be performed (20 cc volume with flow rate of 20 cc/sec at 700 psi) to look for adequacy of balloon size
Balloon inflation with disappearance of the waist
Balloon Deflation
  • Immediately after balloon inflation and complete expansion, deflate the balloon by applying negative 60 cc syringe and while maintaining negative pressure pull rapidly deflating balloon into the ascending aorta and wait for restoration of aortic waveform (for CABG cases pull the balloon in the descending aorta to avoid graft compromise).
  • If hypotension or bradycardia persists, then administer phenylephrine and atropine as needed and be vigilant of other causes of hypotension (tamponade, aortic dissection, retroperitoneal bleed).
  • Pull the balloon out with negative pressure on the 60 cc syringe usually through the arterial sheath.
  • If the balloon is stuck in the sheath, then take the balloon and sheath out while maintaining the wire in LV under fluoroscopy and replace with a new sheath over the wire.
 Post-procedure Assessment
  • Recheck the transvalvular pressure gradient with AR2 catheter in LV and side port of femoral arterial sheath (peak to peak).
    • If the gradient is reduced by 2/3rd of the initial gradient or the valve area doubles, then the procedure is considered successful.
    • If not, then repeat the procedure with a larger balloon.
  • Pull AR2 catheter in the aorta and perform aortogram in LAO 30o view to evaluate the aortic regurgitation post BAV.
  • Remove the temporary pacemaker, and reintroduce the PA catheter to measure PA, PCWP and CO.
 Complications
  • Differential causes of hypotension (including access-related hemorrhage, tamponade, LV rupture and aortic dissection)
  • Acute aortic regurgitation
 Sheath Removal
  • Arterial access is closed with 2 Preclose sutures
Post-procedure Management and Monitoring
  • CCU care.