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.
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high adverse events with BAV in calcific AS reported in the past-PARTNER days are now proven to be either exaggerated, outdated, or outright false.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!
Dr.S.Venkatesan MD 