What is the PTBTV (Percutaneous Transcatheter Balloon Valvotomy) technique for bioprosthetic valve stenosis using?

Percutaneous Transcatheter Balloon Valvotomy (PTBTV) for Bioprosthetic Valve Stenosis

For patients with bioprosthetic valve stenosis who are at high or prohibitive surgical risk, percutaneous transcatheter balloon valvotomy (PTBTV) is a reasonable treatment option to improve hemodynamics and relieve symptoms when performed at a Comprehensive Valve Center. 1

Diagnosis of Bioprosthetic Valve Stenosis

• Comprehensive evaluation with transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) is recommended to diagnose the cause and severity of bioprosthetic valve obstruction, assess ventricular function, and estimate pulmonary artery systolic pressure 2
• 3D TEE or 4D CT imaging is particularly useful to rule out leaflet thrombosis as a cause of bioprosthetic valve stenosis 2
• Assessment should include measurement of mean transvalvular gradient and calculation of effective orifice area using the continuity equation 1
• Evaluation of valve leaflet mobility, thickening, and calcification is essential to determine the mechanism of stenosis 1

Treatment Algorithm for Bioprosthetic Valve Stenosis

First-line Treatment Options:

1. Surgical Intervention:

   • Repeat surgical valve replacement is indicated for patients with symptomatic severe bioprosthetic valve stenosis who have acceptable surgical risk 2
   • This approach offers higher cumulative survival rates and is associated with reduced incidence of patient-prosthesis mismatch and paravalvular leak compared to transcatheter approaches 2

2. Oral Anticoagulation:

   • For patients with significant bioprosthetic valve stenosis due to suspected or documented valve thrombosis, a trial of oral anticoagulation with a vitamin K antagonist (VKA) is reasonable before considering mechanical intervention 2
   • Leaflet thrombosis can occur from 1 month to years after implantation and may be reversible with anticoagulation therapy 2

3. Transcatheter Options for High-Risk Patients:

   • For severely symptomatic patients with bioprosthetic valve stenosis who are at high or prohibitive surgical risk, transcatheter options include:
     • Transcatheter valve-in-valve (ViV) procedure at a Comprehensive Valve Center 2
     • Percutaneous transcatheter balloon valvotomy (PTBTV) for selected patients 1, 3

PTBTV Technique for Bioprosthetic Valve Stenosis

Patient Selection:

• Best candidates are those with:
  • Symptomatic bioprosthetic valve stenosis 3
  • High or prohibitive surgical risk 3
  • Need for immediate hemodynamic improvement 3
  • Valve morphology suitable for balloon dilation (less calcified valves) 3, 4

Procedural Technique:

• Standard Approach:

  • Access via femoral vein for tricuspid valves or transseptal approach for mitral valves 3, 4
  • Use of specialized balloon catheters (e.g., Inoue balloon) sized appropriately for the specific bioprosthesis 4
  • For bioprosthetic tricuspid valve stenosis, a double balloon technique may be employed 1, 3
  • Gradual inflation under echocardiographic and fluoroscopic guidance 3

• Technical Considerations:

  • Careful identification of the bioprosthetic valve design and fluoroscopic appearance is crucial for procedural success 5
  • Balloon sizing should be based on the internal diameter of the bioprosthetic valve 3, 4
  • Stepwise inflation with hemodynamic assessment between inflations 3

Outcomes and Limitations:

• Success rates vary, with literature review showing favorable results in selected cases 3, 4
• Immediate hemodynamic improvement can be achieved in successful cases 3, 4
• Limited durability compared to surgical replacement or valve-in-valve procedures 3
• Risk of complications including:
  • Valve leaflet damage 3
  • Embolization 3
  • Incomplete relief of stenosis 3

Important Considerations and Caveats

• Valve-specific factors:

  • The design and type of bioprosthetic valve significantly impact the feasibility and success of PTBTV 5
  • Stented versus stentless bioprostheses require different approaches 6

• Potential complications:

  • Risk of coronary obstruction, particularly with certain valve types (e.g., Mitroflow bioprostheses) 7
  • Possibility of creating significant regurgitation if valve leaflets are damaged 3

• Alternative approaches:

  • Valve-in-valve TAVI has more robust evidence and may be preferred over PTBTV in many cases 2
  • The VIVID registry showed 93% of survivors with good functional status (NYHA class I/II) after valve-in-valve procedures 2

• Decision-making:

  • Heart team evaluation at a Comprehensive Valve Center is essential for optimal patient selection and procedural planning 2, 1
  • PTBTV may serve as a bridge to more definitive therapy in critically ill patients who cannot immediately undergo surgery or valve-in-valve procedures 3