In a high‑risk patient with bicuspid severe aortic stenosis awaiting transcatheter aortic valve replacement, can balloon aortic valvuloplasty be used as a temporary bridge, and what are the recommended technique, timing, and antiplatelet regimen?

Balloon Aortic Valvuloplasty as a Bridge to TAVR

Balloon aortic valvuloplasty (BAV) is appropriate as a temporary bridge to TAVR in high-risk patients with bicuspid severe aortic stenosis who are hemodynamically unstable or require urgent noncardiac surgery, but it should never be used as definitive therapy. 1

Primary Indications for BAV as Bridge to TAVR

BAV is rated as "May Be Appropriate" or "Appropriate" in the following specific scenarios 1:

• Hemodynamically unstable patients with refractory pulmonary edema or cardiogenic shock awaiting definitive valve replacement 1
• Bridge to decision in patients with severe left ventricular dysfunction or symptoms of uncertain origin to determine if they will benefit from TAVR 1, 2
• Urgent major noncardiac surgery in symptomatic patients when immediate TAVR is not feasible 1
• Palliation in patients temporarily unsuitable for TAVR due to active infection, malignancy requiring treatment, or other reversible contraindications 1, 3

Critical Limitations and Expectations

BAV provides only temporary relief with poor durability 1:

• Aortic valve area rarely exceeds 1.0 cm² post-procedure 1
• Restenosis and clinical deterioration occur within 6-12 months in most patients 1
• Serious acute complications occur in >10% of cases 1
• One-year mortality is 56.2% in patients treated with BAV alone versus 13.3% in those bridged to definitive therapy 2

Recommended Technique

Modern transradial approach with wire-based pacing 4:

• Access via radial or femoral artery (transradial preferred when feasible to reduce vascular complications) 4
• Pacing delivered through the guidewire eliminates need for separate pacing catheter 4
• Balloon sizing to annular diameter (typically 20-25mm) 4
• Rapid ventricular pacing during inflation (180-220 bpm) 4
• Gradual balloon inflation to minimize risk of annular rupture or severe aortic regurgitation 4

Timing Strategy

Proceed to TAVR within 8 weeks to 7 months after BAV 5:

• Success rates for bridging to definitive therapy range from 26.3-74% 6, 5
• Delays beyond this window significantly increase mortality 5
• In hemodynamically stable patients, optimize comorbidities during the bridge period 2
• For cardiogenic shock patients, consider TAVR as soon as hemodynamically stabilized (days to weeks) 1, 3

Antiplatelet Regimen

While guidelines do not specify a unique antiplatelet regimen for BAV as bridge to TAVR, standard post-BAV management includes 4:

• Aspirin 75-100mg daily indefinitely 4
• Consider adding clopidogrel 75mg daily if significant vascular trauma or if TAVR planned within weeks 4
• Avoid aggressive anticoagulation unless specific indication (e.g., atrial fibrillation), as it increases bleeding risk 7

Specific Considerations for Bicuspid Aortic Stenosis

Bicuspid anatomy presents unique challenges 4:

• Higher risk of annular injury during BAV due to asymmetric calcification 4
• May require more aggressive balloon sizing for adequate gradient reduction 4
• Careful TAVR planning required as bicuspid anatomy increases risk of paravalvular leak and device malposition 4
• Consider CT imaging post-BAV to reassess annular dimensions and calcium distribution before TAVR 4

Monitoring During Bridge Period

Close surveillance is mandatory 7, 8:

• Serial clinical assessments every 1-2 weeks 7
• Repeat echocardiography if clinical deterioration 7, 8
• Avoid aggressive diuresis (precipitates cardiovascular collapse in preload-dependent patients) 7, 8
• Avoid vasodilators (cause profound hypotension due to fixed cardiac output) 7, 8
• Maintain heart rate control (slower rates optimize diastolic filling) 8

Common Pitfalls to Avoid

Critical errors that worsen outcomes 7, 8:

• Never use BAV as definitive therapy - it does not alter the natural history of severe AS 1, 7
• Do not delay TAVR once patient is stabilized and suitable 5, 2
• Avoid repeat BAV unless absolutely necessary as bridge (increases complications without improving long-term outcomes) 6
• Do not perform BAV in patients with life expectancy <12 months from non-cardiac causes or severe dementia (medical management is more appropriate) 1, 7

Expected Outcomes

Hemodynamic improvement is modest but clinically meaningful 3, 6:

• Mean gradient reduction from 84.6 mmHg to 51.3 mmHg 3
• NYHA class IV symptoms decrease from 60% to 5% post-procedure 3
• Survival at 8 months is 63% with BAV alone 3
• Patients bridged to TAVR have significantly better long-term survival than those receiving BAV only 6, 2

Heart Team Decision-Making

All complex BAV-to-TAVR cases require multidisciplinary evaluation 8:

• Cardiac surgery, interventional cardiology, cardiac imaging, anesthesiology expertise 8
• Determine optimal timing of TAVR after BAV 8
• Assess for concurrent coronary disease requiring intervention 1
• Evaluate frailty and functional recovery potential 1, 8