bav vs tavr | Dr.S.Venkatesan MD

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No, we can’t allow BAV, to be a threat for TAVR !

Posted in bav vs tavr, TAVR, TAVR /TAVI, tavr tavi, TAVR VS SAVR, Uncategorized on September 18, 2023|

Interventional cardiologists generally do not believe (rather relish) in simple balloon dilatations to remove any vascular blocks. It is a mundane job for their talent-rich hands. After conquering the coronaries, we made exclusive valvular stents. No surprise, TAVR has taken over the aortic interventions with all its glamour and vigor, though it is definitely not an ideal choice in all.

SCAI, the prestigious journal in Interventional cardiology has a recent article , that has a not-so pleasant message for TAVR lovers.

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Very soon, BAV could pose a direct challenge to cardiologists’ heart throb TAVI. Though, it suggests BAV as an adjunct or bridge , there is every reason to belive the bridge can outlive the lives of many co-morbid subsets in TAVR eligible cohorts. (ACC 2014 guidelines already has a grossly under-rated 2B/ Evidence C Indication for BAV)

It seems reasonable to believe BAV, with considerable improvement in hardware, technology, and expertise can be an alternative to TAVR in high-risk aortic stenosis in a substantial number of patients.

It is also worth pondering over a less discussed aspect of BAV. The apparent high adverse events with BAV in calcific AS reported in the past-PARTNER days are now proven to be either exaggerated, outdated, or outright false. (For the evidence seekers, there was never a control BAV arm in none of those big studies on TAVR. It was purely a Surgery vs TAVR study. (A flaw in the aim of the study?) They may call it unethical to have a BAV limb, my understanding is, the absence of which is more unethical, as we claim superiority of TAVR without a less invasive option of BAV as control )

The fact of the matter is, in many centers, the risk of sudden death or acute aortic regurgitation is either comparable to or acceptable when compared to transcatheter aortic valve replacement (TAVR). It is worth emphasizing that BAV can be performed regardless of the load and location of calcium, while TAVR requires minimum elastic calcific load assistance to hold the valve in place. Further, BAV-related issues can now be effectively managed with efficient hemodynamic management.

Final message

If not scientiifally discriminated*, new age BAV can upgrade itself from the “self imposed contraindication” to, a sustainable alternative to TAVR ,atleast in selected sub-group of patients with isolated AS. This reality sould be perceived not only in the cost perspective, but also in the overall superiority in avoiding all those menacing complications with TAVR.

Postamble

*Very difficult task for the humble balloon to prevail over glamarous TAVR. Still,there is some hope(.We can get it from the emerging DEB story, where balloons are able to get rid of stents from the coronaries).

Reference

This is an interesting and important paper in the BAV vs TAVR debate. The funny thing is, even after reading it twice, I am unable to clarify which procedure this paper really favors!

1.Alkhouli M, Zack CJ, Sarraf M, Bashir R, Nishimura RA, Eleid MF, Nkomo VT, Sandhu GS, Gulati R, Greason KL, Holmes DR, Rihal CS. Morbidity and Mortality Associated With Balloon Aortic Valvuloplasty: A National Perspective. Circ Cardiovasc Interv. 2017 May;10(5):e004481. doi: 10.1161/CIRCINTERVENTIONS.116.004481. PMID: 28495894.

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Balloon Aortic valvuloplasty (BAV) will be back with a bang . . . should pose a genuine threat to TAVR !

Posted in baloon aortic valvotomy, bav vs tavr, tagged bav vs tavr, current status of baloon aortic valvotomy on August 30, 2016| Leave a Comment »

Interventional Cardiologist’s favourite play time is to get rid of of obstructions across any blood vessel , valve or a conduit . This has been well practiced for over 2 decades in both coronary and valvular obstruction.Now they wanted more and have since started implanting valves percutaneously. (Aortic valve -TAVR in particular )

Why do balloons work in Mitral stenosis but not in Aortic stenosis ?

It remains a mystery at-least to me ,how PTMC (Percutaneous mitral commissurotomy ) became a default strategy for relieving mitral valve stenosis, while BAV (Balloon Aortic valvotomy) was never considered good enough for opening Aortic stenosis.

The reason is, mitral stenosis(Rheumatic) primarily involve the commissures, while degenerative aortic stenosis involve leaflets more and calcification is much extensive and hence balloons are less effective .Since the initial reports of BAV had more complication like stroke , AR, the interest has waned (except in children with BCAV ).

The arrival of TAVR in big way has made things difficult for BAV to prove its real worth and at best it was considered a bridge therapy.Curiously , BAV is often used as an integral part of TAVR as pre-dilatation with various wires across the valve.Hence , every procedure of TAVR,whether you like it or not carries the huge risk of BAV (please note,these are the same risk which made it unpopular earlier !)

Now , with accumulating data(Funny we got trained in BAV during TAVR we have double confirmed BAV is not that risky after all, even in calcific aortic valve. We also learnt BAV does open up the valve significantly (exact gain contributed by BAV during the TAVR is not quantified as yet).Hence many believe BAV is grossly underutilized modality .

Final message (As usual , without evidence )

BAV, considered just a bridge therapy to TAVR/SVR , (mind you,it may not be flimsy bridge , but a near permanent steel bridge that can outsmart the much hyped TAVR!) Let us recall again the mitral valve logic where you just require dilatation for stenosis .Some degree of AR during BAV is acceptable as do we accept MR in PTMC.As I said earlier the perceived complications of BAV has rapidly declined. For those who are interested in health economics , a single patient’s cost of TAVR can be shared and could confer a fresh bout of life to 20 patients with severe aortic stenosis who can be tackled well with BAV.

I agree , BAV can not reach the glory of PTMC, but definitely its going to come back and expected to give a tough fight to TAVR in atleast high risk patients.BAV has a potential to become a therapy of choice in patients with critical aortic stenosis with severe LV dysfunction as even a small gain in orifice with a balloon can provide a big booster effect on LV function.

A thought and a counter

BAV is retro technique with low efficiency and with high complication rate .

However, isn’t ironical , complications with TAVR ,which includes 25 % of permanent pacemaker assistance is accepted .(with a pride ?) while that of BAV is magnified and made to look unacceptable.Of course , many have mastered BAV and complications has come down recently .I have heard few anecdotal examples where TAVR was abandonded for some reason after pre-dilating the aortic valve and patient doing fine with BAV in the long term.Its being predicted BAV is going to reemerge (already is !) as a useful strategy in critical calcific Aortic stenosis

The emprical utterrings in this discussion are dangerous and unethical and not evidence based !

It would appear “not doing” a large randomised trial comparing one to one (BAV vs TAVR) in a real “high risk” setting of AS amounts to ” unethical” act as complication with BAV has grossly reduced in recent times ! Its our duty to provide best or near best to our patients.Let us ensure reasonable inferiority/Non inferiority is accepted that can prevail over a perceived superior modality , if it comes at low cost !

Further reading