**5. Role of diagnostic balloon aortic valvuloplasty**

In 1986, Cribier et al. [55] first described balloon aortic valvuloplasty (BAV) as a treatment strategy for patients with symptomatic severe AS presenting in cardiogenic shock, or who were deemed too high risk for conventional SAVR. Due to procedural complications, high incidence of restenosis within 6 months, lack of sustained clinical and hemodynamic benefit, BAV was not routinely performed. Furthermore, mortality rates within a year of BAV was similar to others with severe AS who were managed conservatively [56].

**Table 1** lists the current status of BAV according to major guidelines. BAV has a class IIb recommendation for use as a bridge therapy to TAVR or SAVR in hemodynamically unstable patients at high risk for surgery. In the European guidelines (2017) BAV is recommended as a palliative measure in patients not suitable for TAVR or SAVR and in patients with symptomatic severe AS who require urgent noncardiac surgery. The American Heart Association (AHA)/American College of Cardiology (ACC) guidelines (2014) are similar to the European guidelines except they do not recommend the use of BAV as a palliative procedure nor its use in patients undergoing urgent non-cardiac surgery. However it does acknowledge that some patients report an improvement in their symptoms post BAV. The role of BAV as bridge to decision in high-risk patients has been supported by a number of studies [57]. The rationale behind such a strategy is listed below.


**25**

**Author details**

**6. Conclusion**

**Table 1.**

Faeez Mohamad Ali1

provided the original work is properly cited.

1 Waikato Hospital, Hamilton, New Zealand

Rajesh Nair—proctor for Medtronic.

\*Address all correspondence to: drrnair@gmail.com

2 Nelson Hospital, New Zealand

the immediate and long term.

**Conflict of interest**

, Vindhya Wilson2

Faeez Mohamad Ali and Vindhya Wilson—no conflict of interest.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Clinicians should be mindful that patients with symptomatic severe AS may well have low flow and thereby low gradient. Occasionally symptoms may represent severity of underlying heart failure rather than the severity of AS. Established minimally invasive trans-catheter therapies, although has improved associated morbidities of SAVR for intermediate and high-risk patients, it is important that treatment is directed to those who will benefit the most. Accurate diagnosis of severe AS is important as treatment modalities and its timing can offer prognostic benefits in

*Summary of ESC and ACC/AHA guidelines for the role of BAV in managing symptomatic severe AS.*

and Rajesh Nair1

\*

*Low Flow Low Gradient Severe Aortic Stenosis: Diagnosis and Treatment*

*DOI: http://dx.doi.org/10.5772/intechopen.84435*

*Low Flow Low Gradient Severe Aortic Stenosis: Diagnosis and Treatment DOI: http://dx.doi.org/10.5772/intechopen.84435*

#### **Table 1.**

*Aortic Stenosis - Current Perspectives*

with better 1-year survival compared with SAVR in patients with paradoxical LFLG AS in the PARTNER-I Cohort A trial. Further studies are needed to confirm the

In 1986, Cribier et al. [55] first described balloon aortic valvuloplasty (BAV) as a treatment strategy for patients with symptomatic severe AS presenting in cardiogenic shock, or who were deemed too high risk for conventional SAVR. Due to procedural complications, high incidence of restenosis within 6 months, lack of sustained clinical and hemodynamic benefit, BAV was not routinely performed. Furthermore, mortality rates within a year of BAV was similar to others with severe

**Table 1** lists the current status of BAV according to major guidelines. BAV has a class IIb recommendation for use as a bridge therapy to TAVR or SAVR in hemodynamically unstable patients at high risk for surgery. In the European guidelines (2017) BAV is recommended as a palliative measure in patients not suitable for TAVR or SAVR and in patients with symptomatic severe AS who require urgent noncardiac surgery. The American Heart Association (AHA)/American College of Cardiology (ACC) guidelines (2014) are similar to the European guidelines except they do not recommend the use of BAV as a palliative procedure nor its use in patients undergoing urgent non-cardiac surgery. However it does acknowledge that some patients report an improvement in their symptoms post BAV. The role of BAV as bridge to decision in high-risk patients has been supported by a number of

i.BAV helps to choose the best therapeutic option for each patient; avoiding expensive or high risk intervention for patients who may not have prognostic

ii.BAV may be utilized to palliate symptoms and reduce operative risk while

concomitant severe pulmonary disease. The improvement in symptom status post BAV can attribute dyspnea to severe AS rather than lung disease alone.

iv.DSE is used to assess contractile reserve in patients with severe AS. It helps in diagnosis and predicting perioperative mortality but cannot predict LV function recovery. In this subgroup of patients, LV function can be reassessed after 4–8 weeks after "diagnostic" BAV. Recovery of LV function post BAV is a good indicator of contractile reserve and predicts sustained LV function

v.It has been demonstrated that nearly 50% of patients with severe AS and coexistent mitral regurgitation (MR) showed a reduction in the magnitude of MR after BAV [59]. A similar reduction is also seen with pulmonary artery systolic pressure [60]. BAV therefore negates the need for multiple valve

vi.BAV may be used as a palliative procedure in patients with serious comorbidities, frailty, cognitive alteration, severe lung disease or life expectancy

intervention and reduces the overall the risk of SAVR.

iii.BAV may be used as a diagnostic procedure especially in patients with

potential superiority of TAVR versus SAVR in this subset of patients.

**5. Role of diagnostic balloon aortic valvuloplasty**

studies [57]. The rationale behind such a strategy is listed below.

benefit from definitive treatment of AS.

improvement post SAVR/TAVR [58].

awaiting TAVR or SAVR.

AS who were managed conservatively [56].

**24**

less than a year.

*Summary of ESC and ACC/AHA guidelines for the role of BAV in managing symptomatic severe AS.*
