Editorial comment
Balloon aortic valvuloplasty in the transcatheter aortic valve replacement era: A challenge to organization of the heart team
Valvuloplastia aórtica de balão na era das válvulas aórticas percutâneas. Um desafio à dimensão organizativa dos programas multidisciplinares
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COP: cardiorespiratory optimal point; VO<span class="elsevierStyleInf">2</span>max: maximum oxygen uptake.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Plínio S. Ramos, Claudio Gil S. Araújo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Plínio S." "apellidos" => "Ramos" ] 1 => array:2 [ "nombre" => "Claudio Gil S." "apellidos" => "Araújo" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300909?idApp=UINPBA00004E" "url" => "/21742049/0000003600000004/v1_201704230025/S2174204917300909/v1_201704230025/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204917300892" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.09.010" "estado" => "S300" "fechaPublicacion" => "2017-04-01" "aid" => "967" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:251-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2845 "formatos" => array:3 [ "EPUB" => 194 "HTML" => 2261 "PDF" => 390 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Balloon aortic valvuloplasty in the transcatheter aortic valve implantation era: A single-center registry" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "251" "paginaFinal" => "256" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Valvuloplastia aórtica por balão na era da implantação de válvula aórtica percutânea. Um registo unicêntrico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1307 "Ancho" => 3234 "Tamanyo" => 239801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A) Two-year Kaplan-Meier survival curves of patients undergoing TAVI after BAV vs. those maintained under medical therapy; (B) two-year Kaplan-Meier survival curves of patients undergoing TAVI or SAVR after BAV vs. those maintained under medical therapy. 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Um registo unicêntrico" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1307 "Ancho" => 3234 "Tamanyo" => 239801 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(A) Two-year Kaplan-Meier survival curves of patients undergoing TAVI after BAV vs. those maintained under medical therapy; (B) two-year Kaplan-Meier survival curves of patients undergoing TAVI or SAVR after BAV vs. those maintained under medical therapy. BAV: balloon aortic valvuloplasty; SAVR: surgical aortic valve replacement; TAVI: transcatheter aortic valve implantation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Rita G. Francisco, Miguel Nobre Menezes, Pedro Carrilho Ferreira, Cláudia Jorge, Doroteia Silva, Eduardo Infante de Oliveira, Fausto J. Pinto, Pedro Canas da Silva" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Ana Rita G." "apellidos" => "Francisco" ] 1 => array:2 [ "nombre" => "Miguel" "apellidos" => "Nobre Menezes" ] 2 => array:2 [ "nombre" => "Pedro" "apellidos" => "Carrilho Ferreira" ] 3 => array:2 [ "nombre" => "Cláudia" "apellidos" => "Jorge" ] 4 => array:2 [ "nombre" => "Doroteia" "apellidos" => "Silva" ] 5 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Infante de Oliveira" ] 6 => array:2 [ "nombre" => "Fausto J." "apellidos" => "Pinto" ] 7 => array:2 [ "nombre" => "Pedro" "apellidos" => "Canas da Silva" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917300892?idApp=UINPBA00004E" "url" => "/21742049/0000003600000004/v1_201704230025/S2174204917300892/v1_201704230025/en/main.assets" ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Balloon aortic valvuloplasty in the transcatheter aortic valve replacement era: A challenge to organization of the heart team" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "259" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Rui Campante Teles" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Rui" "apellidos" => "Campante Teles" "email" => array:1 [ 0 => "rcteles@outlook.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidade de Intervenção Cardiovascular (UNICARV), Hospital de Santa Cruz, CHLO, Carnaxide, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Estudos de Doenças Crónicas (CEDOC), NOVA Medical School, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Valvuloplastia aórtica de balão na era das válvulas aórticas percutâneas. Um desafio à dimensão organizativa dos programas multidisciplinares" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Balloon aortic valvuloplasty (BAV), first introduced by Cribier et al. in 1986, has seen a resurgence in popularity in the transcatheter aortic valve replacement (TAVR) era.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a> Thanks to improved training and technical advances, BAV is now safer, with periprocedural mortality of 2.2% and in-hospital mortality of 7.1%, and rates of stroke of 1.1%, severe aortic regurgitation of 1.1% and major vascular complications of 7.0%, even though today's patients are more complex and hemodynamic improvement remains modest.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the increasing use of TAVR, the main challenges of BAV nowadays are related to organization of the heart team to treat aortic stenosis, the most common valve disease in developed countries. Portugal's population currently includes around a million people aged over 75 years, 3.4% of whom present severe aortic stenosis and of these, 75% are symptomatic.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> Of these 25<span class="elsevierStyleHsp" style=""></span>000 individuals, around 4500 will have indication for TAVR due to high surgical risk or inoperability, according to the guidelines on valvular heart disease.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6–8</span></a> The Portuguese TAVR registry includes around 850 implantations from 2007 to 2015, 300 of which were performed in 2015. Although there is no national registry of cardiac surgery, it is estimated that approximately 2000 surgical aortic valve replacement (SAVR) procedures, either isolated or with bypass grafting, were performed in 2015. This corresponds to a BAV/SAVR ratio of 1:6, while the ratio in many other European countries is 1:15.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The pressure on heart teams involved in TAVR has grown as they have had to adapt to an enormous increase in numbers of patients, many of whom do not have a primary indication for TAVR. The major issues to be addressed at present are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0020" class="elsevierStylePara elsevierViewall">Implementation of a fast track protocol, through which clinical assessment and the main diagnostic exams (cardiological and surgical consultations, laboratory tests, cardiac computed tomography, transthoracic and possibly transesophageal echocardiography, catheterization and possible angioplasty) can be performed in two or three sessions;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0025" class="elsevierStylePara elsevierViewall">The indications for BAV in the latest guidelines of the European Society of Cardiology and the American College of Cardiology/American Heart Association on valvular heart disease (class IIb recommendation) do not reflect improved outcomes in the TAVR era.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">7,8</span></a> Given that many of the associated complications may recur when initial BAV is followed by TAVR, the situations in which it is acceptable to subject a patient to the increased risk of BAV must be carefully considered:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(a)</span><p id="par0030" class="elsevierStylePara elsevierViewall">BAV is only acceptable as a palliative measure to relieve severe symptoms (on compassionate grounds), or as a bridge to definitive treatment, due to a severe comorbidity, which may be temporary or have an uncertain prognosis, and/or the patient has an expected survival of less than a year (typically due to cancer or an urgent intervention that does not allow for dual antiplatelet therapy, or to enable very elderly patients with other significant and irreversible disease to be discharged home);</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(b)</span><p id="par0035" class="elsevierStylePara elsevierViewall">all other indications for BAV should be carefully weighed, particularly those related to access to prompt treatment, which there is an obligation to provide, or if there are doubts concerning the benefit of TAVR as noninvasive methods can be used for the same purpose (most commonly to treat left ventricular dysfunction and/or severe mitral regurgitation);</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Prompt and appropriate action in the event of complications: once the indication has been established, survival is 1-3 years in symptomatic patients.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,10,11</span></a> Whatever the therapeutic option, however arbitrary the decision may be, the procedure should be performed within two weeks to two months, depending on severity. In the case of BAV, since this is a palliative procedure the possibility of clinical instability or complications that can be treated by TAVR – typically severe aortic regurgitation or stroke – must be borne in mind, and the heart team must be prepared to proceed with TAVR (an appropriate device being readied) and/or bailout surgery, as in TAVR.</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">The article by Francisco et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> published in this issue of the <span class="elsevierStyleItalic">Journal</span> provides valuable information that enables the importance of BAV to be judged in the light of the above considerations. The study, a retrospective analysis of the experience of a high-volume TAVR center in patients who had undergone BAV, concludes that the procedure led to significant improvement in most patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The study's principal merit is that it is the first to analyze a Portuguese experience in the TAVR era. It is based on a single-center observational registry of 23 patients treated between January 2005 and October 2013, and compares outcomes with larger previous series of 45-473 individuals. Patients were followed for around nine months and the results were analyzed retrospectively.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The most frequent indication for BAV was as a bridge to definitive treatment (43% of cases), unlike most other series, in which the main indication was palliative, with only 18% as a bridge. Except for a higher prevalence of diabetes, this cohort is generally less complex than others, both demographically and clinically.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In terms of technical details, the article does not specify how balloon size was determined or how rapid pacing was performed, particularly by what access route or the rate achieved, since a sustained pressure fall is crucial for stable balloon positioning. Undersizing the balloon by 1-2 mm allows for a less aggressive approach, which, together with smaller introducers and vascular closure devices, appears to be responsible for the reduced rate of complications seen nowadays.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There was no periprocedural mortality or severe aortic regurgitation. There was one in-hospital death due to stroke (4.3%) and the rate of major vascular complications was 8.6%; it should be borne in mind that three refractory patients under mechanical ventilation were successfully extubated. The favorable course at nine months of the patients treated definitively by TAVR attests to the effectiveness of the stratification process and the reasonable outcomes now achieved with the technique.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, the study by Francisco et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> is significant for its analysis of the current risk associated with BAV in Portuguese patients in the TAVR era. Prediction of the risk of palliative treatment is important and heart teams should be organized in such a way as to provide a rapid response to patients with indication for TAVR, thus avoiding BAV as a palliative procedure for those awaiting definitive treatment by TAVR or SAVR, since complications remain significant despite the experienced gained.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Campante Teles R. Valvuloplastia aórtica de balão na era das válvulas aórticas percutâneas. Um desafio à dimensão organizativa dos programas multidisciplinares. Rev Port Cardiol. 2017;36:257–259.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Cribier" 1 => "T. Savin" 2 => "N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 6 | 10 |
| 2024 October | 35 | 25 | 60 |
| 2024 September | 57 | 25 | 82 |
| 2024 August | 43 | 31 | 74 |
| 2024 July | 30 | 41 | 71 |
| 2024 June | 22 | 14 | 36 |
| 2024 May | 28 | 28 | 56 |
| 2024 April | 23 | 24 | 47 |
| 2024 March | 30 | 30 | 60 |
| 2024 February | 26 | 25 | 51 |
| 2024 January | 19 | 24 | 43 |
| 2023 December | 18 | 27 | 45 |
| 2023 November | 25 | 27 | 52 |
| 2023 October | 18 | 15 | 33 |
| 2023 September | 30 | 22 | 52 |
| 2023 August | 27 | 10 | 37 |
| 2023 July | 19 | 14 | 33 |
| 2023 June | 15 | 15 | 30 |
| 2023 May | 31 | 21 | 52 |
| 2023 April | 20 | 2 | 22 |
| 2023 March | 20 | 20 | 40 |
| 2023 February | 33 | 19 | 52 |
| 2023 January | 19 | 14 | 33 |
| 2022 December | 19 | 22 | 41 |
| 2022 November | 42 | 20 | 62 |
| 2022 October | 28 | 19 | 47 |
| 2022 September | 25 | 36 | 61 |
| 2022 August | 22 | 25 | 47 |
| 2022 July | 24 | 32 | 56 |
| 2022 June | 22 | 24 | 46 |
| 2022 May | 23 | 30 | 53 |
| 2022 April | 18 | 30 | 48 |
| 2022 March | 25 | 47 | 72 |
| 2022 February | 28 | 38 | 66 |
| 2022 January | 35 | 28 | 63 |
| 2021 December | 20 | 27 | 47 |
| 2021 November | 27 | 45 | 72 |
| 2021 October | 36 | 46 | 82 |
| 2021 September | 23 | 26 | 49 |
| 2021 August | 32 | 35 | 67 |
| 2021 July | 23 | 28 | 51 |
| 2021 June | 25 | 11 | 36 |
| 2021 May | 34 | 48 | 82 |
| 2021 April | 37 | 21 | 58 |
| 2021 March | 56 | 12 | 68 |
| 2021 February | 67 | 25 | 92 |
| 2021 January | 38 | 19 | 57 |
| 2020 December | 38 | 12 | 50 |
| 2020 November | 41 | 15 | 56 |
| 2020 October | 18 | 10 | 28 |
| 2020 September | 48 | 17 | 65 |
| 2020 August | 27 | 12 | 39 |
| 2020 July | 40 | 15 | 55 |
| 2020 June | 28 | 13 | 41 |
| 2020 May | 41 | 6 | 47 |
| 2020 April | 38 | 15 | 53 |
| 2020 March | 38 | 9 | 47 |
| 2020 February | 52 | 30 | 82 |
| 2020 January | 43 | 9 | 52 |
| 2019 December | 36 | 4 | 40 |
| 2019 November | 32 | 9 | 41 |
| 2019 October | 32 | 8 | 40 |
| 2019 September | 20 | 10 | 30 |
| 2019 August | 32 | 6 | 38 |
| 2019 July | 34 | 7 | 41 |
| 2019 June | 21 | 13 | 34 |
| 2019 May | 34 | 7 | 41 |
| 2019 April | 32 | 13 | 45 |
| 2019 March | 101 | 8 | 109 |
| 2019 February | 68 | 9 | 77 |
| 2019 January | 43 | 3 | 46 |
| 2018 December | 28 | 11 | 39 |
| 2018 November | 97 | 21 | 118 |
| 2018 October | 206 | 25 | 231 |
| 2018 September | 42 | 11 | 53 |
| 2018 August | 53 | 9 | 62 |
| 2018 July | 28 | 8 | 36 |
| 2018 June | 43 | 8 | 51 |
| 2018 May | 62 | 10 | 72 |
| 2018 April | 66 | 7 | 73 |
| 2018 March | 85 | 9 | 94 |
| 2018 February | 37 | 5 | 42 |
| 2018 January | 25 | 6 | 31 |
| 2017 December | 50 | 15 | 65 |
| 2017 November | 53 | 11 | 64 |
| 2017 October | 35 | 14 | 49 |
| 2017 September | 29 | 8 | 37 |
| 2017 August | 33 | 14 | 47 |
| 2017 July | 30 | 13 | 43 |
| 2017 June | 55 | 16 | 71 |
| 2017 May | 112 | 32 | 144 |
| 2017 April | 169 | 18 | 187 |
| 2017 March | 0 | 1 | 1 |
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