19.1 Valvuloplasty

Valvuloplasty

ARRT Cardiac-Interventional Procedures 2.B.4 is valvuloplasty. The same interventional Focus of Questions used throughout 2.B applies on every balloon: anatomy and pathophysiology, indications, contraindications, imaging, access, ultrasound, equipment, complications, and closure. This is balloon therapy of a native valve (or, less often, a degenerated bioprosthesis). It is not TAVR (18.3), not edge-to-edge mitral repair (19.2), and not an LAA occluder (19.3).

Quick Answer: Balloon aortic valvuloplasty (BAV) is a bridge, palliation, or predilation for TAVR. Use rapid RV pacing and typically femoral arterial access. Watch acute AR, annular injury, stroke, and access injury. Balloon mitral valvuloplasty (BMV/PMBV) is for selected rheumatic mitral stenosis (MS) with a favorable Wilkins morphology — mobile, thin leaflets and little calcium. Access is femoral venous then transseptal. The classic balloon is Inoue-class. Contraindications: LA thrombus, severe MR, bicommissural calcium. Pulmonic valvuloplasty is the congenital PS analogue, usually from the femoral vein.

Anatomy and pathophysiology

Aortic stenosis (AS) in adults is usually calcific (senile/degenerative) on a trileaflet valve, or a bicuspid valve that calcifies earlier. The orifice will not open; LV pressure overload, hypertrophy, and eventually heart failure or shock follow. A BAV balloon cracks calcium and splits fused commissures. It does not implant a valve. The transvalvular gradient falls for a while; restenosis is expected. That is why standalone BAV is not durable destination therapy for most calcific AS — TAVR or surgery is the durable fix (18.3). BAV still matters because a crashing patient may need a temporary orifice before a valve can be delivered, and a TAVR system may not cross until the native valve is ballooned.

Mitral stenosis that is balloonable is typically rheumatic: commissural fusion, a hockey-stick anterior leaflet on echo, elevated left-atrial pressure, and pulmonary hypertension. The Inoue balloon is meant to split commissures, not to smash a heavily calcified degenerative mitral annulus. Degenerative calcific MS is a different disease and is not the classic PMBV story. Splitting the wrong substrate (rigid calcium in both commissures) tears leaflet tissue and creates severe MR instead of a larger orifice.

Pulmonic stenosis (PS) in teaching is usually congenital (doming leaflets, a high RV-to-PA peak-to-peak gradient). The balloon splits the dome. Dynamic infundibular muscle can spasm after a successful pulmonary balloon — a different obstruction from residual valvular stenosis, and not a reason to upsize the same balloon at the annulus.

Balloon aortic valvuloplasty

Indications (teaching):

• Bridge to TAVR or SAVR in a patient who is too unstable, too volume-overloaded, or too shocked to go straight to implant or the OR.
• Palliation when the heart team has no TAVR/SAVR path (comorbidity, anatomy, goals of care).
• Predilation so a TAVR delivery system can cross a tightly stenotic native valve, or so a balloon-expandable TAVR frame can open a rigid orifice (18.3).

Contraindications / stops: active endocarditis, LV thrombus, an annulus the operator is not prepared to injure, and a lab that cannot treat acute severe AR or annular rupture. Do not treat BAV as a casual substitute for TAVR in a patient who is a TAVR candidate. Standalone BAV as “the valve replacement” is the exam trap.

Access. Femoral arterial, retrograde across the aortic valve, is the workhorse. Sheaths are larger than diagnostic LHC. Vascular ultrasound guides the stick; iliofemoral angiography or a TAVR-planning CT warns of a vessel that will not take the balloon sheath. Rare antegrade transseptal BAV exists; it is not the default exam story. This is an arterial case — closure later is arterial hemostasis, not a figure-of-8 venous stitch alone.

Imaging and ultrasound. Fluoroscopy watches balloon markers at the annulus and the waist as the balloon fills. Rapid right-ventricular pacing (temporary RV wire or LV wire pacing; teaching rates often ~180–220/min — lab teaching, not an unpublished ARRT cutoff) drops stroke volume so the balloon does not eject into the arch or dive into the LV. Confirm capture before inflation. Loss of capture at the moment of inflation is how the balloon jumps and strips the arch or the LV. Aortic root angiography and TTE/TEE look for new AR. Vascular ultrasound later diagnoses the access hematoma or occlusion.

Equipment. Large-diameter aortic valvuloplasty balloons (cylindrical or mildly waisted teaching designs). Size from echo or CT annulus teaching — do not invent unpublished ARRT millimeter cutoffs. Inflate briefly under pacing, deflate fast, restore output. A TAVR predilation balloon is the same family used just before valve crossing; postdilation of a TAVR frame is a different intent (PVL) with the same annular-injury risk (18.3).

Complications: acute AR (leaflet tear or commissural avulsion — sudden hypotension, a wide pulse pressure, and a new diastolic blow), annular injury/rupture (tamponade or mediastinal bleed — hybrid OR / surgery now, 14.1), stroke from calcium or catheter debris, conduction block, restenosis after a “successful” standalone BAV, and large-bore arterial access injury (dissection, occlusion, retroperitoneal bleed). Closure is arterial: suture-mediated preclose or a closure device suited to the sheath, or manual pressure, plus a documented distal pulse.

Balloon mitral valvuloplasty (BMV / PMBV)

Indication: selected rheumatic MS with favorable leaflet morphology. The echo teaching score is the Wilkins (Abascal) score: leaflet mobility, thickening, calcification, and subvalvular thickening, each graded and summed. Favorable morphology for the exam is mobile, thin leaflets and little calcium (and little subvalvular disease). Unfavorable: rigid, thick, calcified leaflets and a fused subvalvular apparatus. Do not treat a specific Wilkins integer as an unpublished ARRT cutoff — teach the morphology, not a memorized magic number. Commissural calcium, especially bicommissural calcium, is its own stop even if someone recites a “good score.”

Contraindications: left-atrial thrombus (especially LAA thrombus — anticoagulate and restudy; do not balloon through clot), severe mitral regurgitation, and bicommissural calcium (the balloon splits the uncalcified commissure and tears the leaflet, producing severe MR). Significant mixed mitral disease that is already severe MR, or MS that is purely calcific-degenerative, is the wrong substrate. Uncontrolled endocarditis is a stop, as on any left-sided implant.

Access, imaging, ultrasound. Femoral venous → RA → transseptal puncture into the LA → mitral valve. TEE or ICE guides the puncture (mid-fossa, avoid the aorta and the posterior wall) and watches MR as the balloon inflates. Exclude thrombus on TEE (or a CT/TEE workup) before you go left-sided. Heparin after the LA is entered is expected; ACT targets are lab protocol, not an unpublished ARRT second. Vascular ultrasound is for the venous stick. This is not femoral arterial BAV, and it is not the PFO “cross the tunnel without a needle” story (18.1) — PMBV does use transseptal puncture.

Equipment. Inoue-class balloon: a waist / hourglass inflated in stages (distal bulb in the LV, pull back to hook the valve, then proximal bulb and waist). Height-based sizing appears in lab protocols — protocol, not an unpublished ARRT centimeter. The balloon is designed to split commissures. Overinflation in a calcified bicommissural valve is how you create severe MR. Single-balloon and metallic commissurotome variants exist historically; the exam-classic device is still Inoue-class.

Complications: severe MR, tamponade from transseptal or LA perforation, an iatrogenic ASD at the puncture (usually small), stroke if thrombus was missed, and venous access bleeding. Closure is venous hemostasis (manual pressure, figure-of-8 stitch, or a venous closure device), not an arterial collagen plug unless you also stuck an artery.

Pulmonic valvuloplasty (conceptually)

Congenital valvular PS (and selected RV–PA conduit stenosis) is ballooned from femoral venous access: IVC → RA → RV → pulmonary valve. No transseptal puncture is required. Imaging is fluoro plus a hemodynamic pullback (peak-to-peak RV-to-PA gradient) and echo. Watch infundibular spasm after the valve opens (dynamic subvalvular obstruction — volume and beta blockade per the implanting service, not another balloon at the annulus). Complications: pulmonary annular or PA injury, pulmonic regurgitation, arrhythmia, and tricuspid injury from stiff rails. This is the right-heart balloon analogue, not TAVR and not an Inoue mitral case.

Table: valve / access / classic indication / contraindication

Worked case

Cardiogenic shock, severe calcific AS, not yet a TAVR implant afternoon. BAV as a bridge: femoral arterial sheath, RV pacing capture confirmed, brief balloon inflation at the annulus, look for new AR and a falling gradient, then plan TAVR. If instead the patient is a 38-year-old with rheumatic MS, mobile thin leaflets, no calcium, no LA thrombus, and mild MR, that is PMBV: TEE, transseptal, Inoue stepwise inflation. If TEE shows LAA thrombus or calcium in both commissures, stop — thrombus is a stroke, bicommissural calcium is severe MR. A teenager with a doming pulmonary valve and a high RV–PA gradient is pulmonic valvuloplasty from the femoral vein — do not start with an arterial BAV balloon, and do not chase post-balloon infundibular Doppler with a larger pulmonary balloon.

Exam traps

• Treating BAV as durable destination therapy for calcific AS.
• Skipping rapid pacing on aortic balloon inflation, or inflating without confirmed capture.
• Ballooning rheumatic MS with LA thrombus, severe MR, or bicommissural calcium.
• Using an arterial approach as the default for PMBV.
• Calling a Wilkins lecture a license to balloon calcific degenerative MS.
• Treating post-pulmonic infundibular spasm with a bigger pulmonary balloon.