Balloon Expandable Transcatheter Aortic Valve Implantation Without Predilation of the Aortic Valve

Prior to the deployment of transcatheter heart valves (THV), balloon aortic valvuloplasty (BAV) is usually performed under rapid right ventricular pacing (burst >180 bpm) with the induction of a functional cardiac arrest for up to 30 seconds. Aortic valve predilation is aiming at facilitating the crossing of the aortic annulus, accurate valve positioning and does also provide information on the anatomy of the valve complex. However, BAV has been shown to have a number of potentially detrimental effects, such as:

• Functional cardiac arrest induced by rapid pacing leads to transient coronary, cerebral, and renal ischemia.
• In patients with a reduced left ventricular ejection fraction (LVEF), prolonged cardiac depression after rapid pacing is observed and may result in hemodynamic failure and systemic inflammatory response syndrome (SIRS). Both are associated with a high periprocedural mortality.
• BAV has been identified as a major source of thrombotic and valvular material and increases the risk for coronary obstruction with subsequent myocardial infarction and stroke.
• The local trauma in the left-ventricular outflow tract caused by BAV may potentially contribute to aortic root rupture.

Inclusion criteria

• Patients with an indication for TAVI as to the Edwards THV IFU
• Eligible for TABI with AND without BAV
• Signed informed consent

Exclusion criteria

• Logistic EuroSCORE I >50%
• Mitral or tricuspid valvular insufficiency (> grade II)
• Previous aortic valve replacement
• Uncontrolled atrial fibrillation
• Left ventricular or atrial thrombus by echocardiography
• Recent cerebrovascular event (within the last 3 months)
• High probability of non-adherence to the follow-up requirements (due to social, psychological or medical reasons)