Percutaneous Balloon Valvuloplasty

For frail elderly patients with aortic stenosis who are not candidates or are high-risk candidates for surgery, balloon valvuloplasty is sometimes performed to relieve symptoms. Also, for mitral stenosis, balloon valvuloplasty is a suitable alternative to surgery for patients with pliable, noncalcified mitral valves.

Prognosis

The mortality rate for balloon aortic valvuloplasty is relatively low: the periprocedural mortality rate is 3%; the 30-day mortality rate is 14%. However, the morbidity rate is relatively high; 31% of patients experience significant complications before discharge, the most common being a need for blood transfusion.

The procedure offers considerable temporary palliation and an acceptable mortality risk even in very ill patients. Even when balloon valvuloplasty is performed in very ill patients who are not surgical candidates, the periprocedural mortality rate is < 5%. The major limitation of balloon aortic valvuloplasty is a very high rate of restenosis. Within 2 years, about 80% of patients have recurrent symptoms leading to a second balloon valvuloplasty, aortic valve replacement, or death. Therefore, patients who are surgical candidates should be treated with surgery.

For mitral stenosis, percutaneous balloon mitral valvuloplasty and surgical commissurotomy for mitral valve stenosis are comparable; they provide similar hemodynamic improvement, symptomatic relief, and intermediate-term symptom-free survival. In patients > 65, the periprocedural mortality rate for percutaneous balloon mitral valvuloplasty is usually <= 3%.

The success of balloon mitral valvuloplasty depends heavily on the characteristics of the diseased valve. Results are best when the mitral valve is pliable, noncalcified, and not severely stenotic. However, in elderly patients with mitral stenosis, the mitral valve is most often thickened, nonpliable, and calcified because of long-term rheumatic disease. Only about 45% of elderly patients with mitral stenosis are good candidates for balloon mitral valvuloplasty.

Preprocedural Assessment

Thorough evaluation with echocardiography is critical for proper patient selection for balloon mitral valvuloplasty. Transesophageal echocardiography is advisable to exclude left atrial thrombi for patients in whom the transatrial septal approach is planned. For elderly patients, coronary angiography is also advisable because the presence of coronary artery disease may alter the approach taken. For patients with less pliable mitral valves, surgical mitral valve replacement must be considered as an alternative treatment.

Postprocedural Treatment

Similar to younger patients, elderly patients may quickly regain mobility after balloon valvuloplasty of the mitral or aortic valve. Serial echocardiography can detect complications (eg, pericardial effusions, cardiac tamponade, valvular regurgitation) and allows assessment of the response to therapy.