In an elderly patient with severe calcified aortic stenosis and significant comorbidities, should balloon aortic valvuloplasty be performed or is definitive valve replacement—surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI)—the preferred treatment?

Balloon Aortic Valvuloplasty in Severe Calcified Aortic Stenosis

Balloon aortic valvuloplasty (BAV) should NOT be performed as definitive therapy in elderly patients with severe calcified aortic stenosis—definitive valve replacement with either TAVI or SAVR is the preferred treatment, with BAV reserved only as a bridge to definitive intervention or for palliation in hemodynamically unstable patients who cannot undergo valve replacement. 1, 2

Why BAV Fails as Definitive Therapy

The evidence against BAV as standalone treatment is unequivocal:

• BAV has low efficacy, high complication rates (>10%), and restenosis with clinical deterioration occurs within 6-12 months in most patients, resulting in mid- and long-term outcomes similar to the natural history of untreated aortic stenosis 1

• Long-term survival data demonstrates the futility of BAV alone: 1-year survival is 63%, 2-year survival drops to 40%, 3-year survival is only 28%, and 4-year survival is a dismal 21%—all statistically worse than age-matched controls 3

• Medical management alone (which BAV essentially mimics in long-term outcomes) is associated with 2-year mortality rates approaching 68% in symptomatic severe AS 2

The Definitive Treatment Standard

Aortic valve replacement (either SAVR or TAVI) is the definitive therapy for severe AS, with symptoms and quality of life greatly improved after successful intervention 1, 4

When to Choose TAVI vs SAVR:

• TAVI is recommended for patients with prohibitive surgical risk (≥50% estimated 30-day mortality or irreversible morbidity) 1, 5

• TAVI is a reasonable alternative to SAVR in high surgical risk patients (STS-PROM score ≥8%) 5, 4

• Additional prohibitive risk factors favoring TAVI include: frailty, prior chest radiation, porcelain aorta, severe hepatic disease, or severe pulmonary disease 1, 5

• For patients ≥80 years old with suitable anatomy, TAVI is recommended 5

• Age alone should never be considered a contraindication for surgery—valve replacement has been shown to prolong and improve quality of life even in selected patients over 80 years of age 1

The Limited Role of BAV: Bridge to Definitive Therapy Only

BAV has only two acceptable indications in contemporary practice:

1. As a bridge to definitive valve replacement (SAVR or TAVI) in patients requiring temporary hemodynamic stabilization 2, 6, 7

2. For palliation in hemodynamically unstable patients who cannot undergo valve replacement 2

BAV as a Bridge: The Evidence

• Success rates for bridging from BAV to definitive surgical intervention range from 26.3-74%, with AVR or TAVI occurring within 8 weeks to 7 months 7

• Up to 40% of patients selected by BAV to have TAVI or AVR do not receive these procedures within 2 years—most are excluded for terminal disease/malignancy or die while waiting 7

• Outcomes in patients bridged to AVR/TAVI are significantly better than in patients treated with BAV only, so delays to progression should be avoided 7

When Intervention May Not Be Appropriate

Medical management (without BAV or valve replacement) may be considered only when life expectancy is <12 months from non-cardiac causes, multiple organ system failure exists, severe frailty precludes functional recovery, or advanced dementia is present 5, 2

In these futility scenarios:

• Palliative BAV is rated as "May Be Appropriate" for temporary symptom relief 2
• TAVR or SAVR would be "Rarely Appropriate" given the inability to improve meaningful outcomes 1

Special Scenario: Urgent Non-Cardiac Surgery

In symptomatic patients with severe AS requiring urgent major non-cardiac surgery:

• No intervention on the AS is "Rarely Appropriate" due to markedly increased perioperative morbidity and mortality 1

• BAV with temporary reduction in stenosis severity is considered "May Be Appropriate" 1

• Definitive SAVR or TAVI is rated "Appropriate" and preferred over BAV 1

Critical Pitfalls to Avoid

• Never use BAV as definitive therapy—it provides only temporary relief and does not alter the dismal natural history 1, 2

• Do not delay valve replacement in symptomatic patients based on "optimizing" medical therapy 2

• Do not assume elderly or frail patients cannot benefit from TAVI—these patients often have the most to gain 5, 2

• Avoid aggressive diuresis in AS patients with heart failure symptoms, as this can precipitate hemodynamic collapse 2