Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going

Degenerative aortic valve stenosis (AS) is the most frequent reason for referral to hospital for valvular heart disease. Despite the advent and widespread availability of transcatheter aortic valve implantation (TAVI) in the last fifteen years, the European Society of Cardiology (ESC) valvular disease survey II demonstrated that 20% of patients with a class I recommendation for valve replacement according to international guidelines actually do not undergo the procedure [1]. As a consequence, a portion of patients with symptomatic AS, typically with high surgical risk, frailty, haemodynamic instability, multiple comorbidities, and old age, are treated with medical therapy and maybe balloon aortic valvuloplasty (BAV) [2].
Notably, 3% to 20% of patients enrolled in TAVI registries suffer from concomitant moderate-to-severe mitral regurgitation (MR) [3, 4]. A meta-analysis including eight studies, with more than 8 000 patients, demonstrated that MR severely impacts overall 30-day and 1-year mortality (odds ratio (OR) = 1.49, 95% CI: 1.16–1.92; hazard ratio (HR) = 1.32, 95% CI: 1.12–1.55, respectively) [5]. As for the aetiology, degenerative MR seems to be associated with increased risk of 2-year cardiovascular death (adjusted HR = 2.21, 95% CI: 1.4–3.49, p = 0.001) compared to functional MR (adjusted HR = 1.13, 95% CI: 0.59–2.18, p = 0.707) [6].
The Study to Improve Outcomes in Aortic Stenosis (IMPULSE) showed that grade III or IV MR was more frequent in symptomatic than asymptomatic patients with severe AS (11.6% vs. 7.1%; p = 0.008), and particularly in those who were denied valve replacement (17.5% vs. 9.1%; p < 0.001) [7]. Indeed, MR is one of the comorbidities sometimes affecting the indication for TAVI or surgical valve replacement (SAVR). A large registry evaluated the role of BAV as a bridge-to-decision in selected patients and showed a post-procedural reduction of moderate-to-severe MR prevalence from 16.3% at baseline to 11.5%. After a second heart team assessment, 70.5% of patients with MR reduction finally became eligible for SAVR/TAVI [8].
In this issue of the journal, Kleczynski et al. illustrated the results of a retrospective analysis of 271 patients with high-gradient AS undergoing BAV from two high-volume centres, assessing separately the echographic outcome of those with (n = 85, 21.2%) and without (n = 186, 78.8%) moderate-to-severe MR. In the former group, several echo parameters significantly improved from...


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