This document discusses percutaneous balloon aortic valvuloplasty (BAV) as a treatment for severe calcific aortic stenosis in high-risk elderly patients not suitable for surgical aortic valve replacement. It provides background on the pathophysiology and current treatment of aortic stenosis, including the limitations of surgical replacement in elderly populations. While BAV was previously abandoned due to high restenosis rates, the document argues that technical improvements and the growing population of very elderly patients make revisiting BAV worthwhile. It reviews the mechanisms and results of BAV, as well as guidelines for selecting patients for the procedure.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
By the end of the module, you will be able to:
Define Arterio Venous Fistula and Arterio Venous Graft
Identify Complications and Management
Familiarise and use the Pre Needling Cannulation Tool
By the end of the module, you will be able to:
Define Arterio Venous Fistula and Arterio Venous Graft
Identify Complications and Management
Familiarise and use the Pre Needling Cannulation Tool
It took another 10 years, after a positive response of a different Review Board,before the first alcohol septal ablation (ASA) could be performed at the Royal Brompton Hospital in London 25 years ago.1
The very first patient, after having been informed in great length and meticulous detail about all possible risks,agreed to an experimental procedure, the outcome of which could not be defined.
She had severe left ventricular hypertrophy that created an impressive and highly
symptomatic outflow tract gradient despite pacing and drug treatment; after the ablation on June 18, 1994, she remained asymptomatic for >20 years.
Endovascular complications: Antiplatelet management for flow diversionbijnnjournal
Up to 3−5% of the general population is affected by cerebral aneurysms that are associated with both modifiable
as well as non-modifiable risk factors ranging from familial to acquired neurovascular conditions. The initial
treatment option was aneurysm clipping and evolved to including primary or adjuvant endovascular treatment.
Aneurysm re-rupture, although rare, can have devastating consequences such as intracranial bleeding and carotidcavernous fistula. Emergent surgery in view of delayed aneurysm rupture in patients maintained on dual antiplatelet
therapy presents with the need to carefully assess the procedure-related risk factors and evaluate the patients’
platelet function. With the advent of novel technology, flow diverters came into play
Despite the advances in diagnostic methods and techniques for surgical treatment in the last two decades, aortic diseases remain a major cause of mortality and cardiovascular morbidity, challenging physicians and molecular biologists. It is believed that about 600 million years ago, during the Cambrian period, variant forms of life appeared, among them were the oxygen-producing cyano bacteria.
Simple liver cysts are congenital or acquired benign cysts formations and are commonly found incidentally. It has a prevalence of 3-5% in ultrasound studies and 18-24% in CT scans. Frequently asymptomatic, liver cysts may be associated with symptoms in 10-16% of patients. Hemoperitoneum is a far rare complication. Herein, we report a case presented at the emergency room with acute hemorrhagic rupture of a liver cyst.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
3. Severely stenotic leaflets have promi-
nent calcification with lipocalcific
changes on the aortic side of leaflet.
Active bone formation is an impor-
tant component of AS.4 Early lesion
initiation results from endothelial layer
disruption caused by mechanical
forces such as shear stress and abnor-
mal blood flow patterns. Lipid accu-
mulation, especially with low-density
lipoprotein, begins within the leaflet
subendothelial layer and is modified
by inflammatory and cytokine interac-
tions. The angiotensin-converting en-
zyme cascade also works locally
within the aortic leaflet, causing fibro-
blasts within the fibrosa layer to dif-
ferentiate into myofibroblasts wherein
the angiotensin I receptor is highly
expressed. The myofibroblast cell
plays a central role in the process
because it is believed to differentiate
into an osteoblast-like cell phenotype,
which in turn promotes deposition of
calcified nodules and bone formation.
Novel Relevant
Pathophysiological Insights
From In Vivo 3-Dimensional
Imaging
Investigations into the relationship be-
tween aortic valve calcium and stenot-
ic area by multislice computed tomog-
raphy show causal mechanisms.5
Three-dimensional images reveal im-
portant information about leaflet calci-
fication and stenosis severity. Figure 2
supports the observation that extraval-
vular calcification affects leaflet motil-
ity, especially when calcium accumu-
lates in the outflow tract and aortic
root. Calcification within these loca-
tions may severely restrict leaflet mo-
tion and enhance stenosis severity.
Current Therapy and
Results
Surgical Replacement
Surgical valve replacement should be
considered the treatment of choice for
severe AS patients regardless of age.
Moderate-to-severe AS occurs in 5%
of individuals 75 to 86 years of age,
and critical AS is seen in Ͼ5% of
those Ͼ85 years of age.6 Increasing
numbers of octogenarians and nonage-
narians are presenting with severe AS
for consideration of open heart sur-
gery, and physicians are increasingly
confronted by the growing dilemma of
finding suitable therapy for elderly pa-
tients who are often poorly suited for
traditional valve replacement surgery.
Surgical success rates for these very
elderly patients are improving but re-
main suboptimal. In-hospital death and
stroke rates may be as high as 8.5%
and 8%, respectively.1 Mean duration
of postoperative hospital stay in most
Figure 1. Layered architecture of normal aortic valve leaflet. The ventricular surface has
a black-staining elastic layer (ventricularis). A dense collagenous layer (fibrosa) extends
toward the aortic surface. The spongiosa is a loose connective tissue layer rich in
proteoglycan.
Figure 2. Three-dimensional volume-rendering images reveal that extravalvular calcifica-
tion of the valve leaflet, especially toward the left ventricle outflow tract, may restrict the
motion of the leaflet, which can be worked as a hinge point.
Hara et al Resurgence of Balloon Valvuloplasty e335
by guest on January 11, 2013http://circ.ahajournals.org/Downloaded from
4. reports is Ͼ2 weeks for very elderly
patients, with most being discharged to
nursing care facilitates. Furthermore,
many elderly patients refuse surgery
despite favorable outcomes, making
less invasive, percutaneous therapy an
attractive option for enhancing their
quality of life. Moreover, disability
often results from aortic valve replace-
ment surgery in elderly patients. Less
specific cognitive deficits also are
common. More than half of all octoge-
narians are discharged to rehabilitation
facilities, even after minimally inva-
sive approaches are used, and Ͼ20%
are rehospitalized within 1 month.7
Aortic Valvuloplasty as a
Forgotten Therapy
Percutaneous aortic valvuloplasty was
developed as a nonsurgical option in
the 1980s. It was found to have a role
in managing unstable and critically ill
patients such as those in cardiogenic
shock or refractory heart failure. A
mean age of 78Ϯ9 years was reported
in the National Heart, Lung and Blood
Institute (NHLBI) valvuloplasty regis-
try and was typical of “younger” pa-
tients who underwent BAV 2 decades
ago. A consistent limitation for this
therapy among younger patients with
greater longevity was the high resteno-
sis rate and the need for reintervention.
BAV was thus found to be of limited
utility for many of these patients who
were acceptable candidates for aortic
valve replacement.
High complication rates and in-
hospital mortality also were reported
early in the experience, suggesting
complications in 25% of patients (167
of 672) within 24 hours of the proce-
dure and documenting death in 3% (17
of 672).8 The most common complica-
tion was transfusion in 20%, related
predominantly to vascular entry site
complications (136 of 672; Table 1).8
Cumulative cardiovascular mortality
before discharge was 8% in the
NHLBI registry. Restenosis and recur-
rent hospitalization were common, al-
though survivors reported fewer symp-
toms over the subsequent 1.5 years.3
Most patients who are very elderly
often are considered too frail to un-
dergo BAV or aortic valve replace-
ment. In a comparable patient popula-
tion without AS, median expected
survival was only 2 years, regardless
of valve condition.9 The most impor-
tant predictor of event-free survival
after BAV was left ventricular func-
tion at baseline (ejection fraction
Ͼ25%).10 BAV may be a forgotten
therapy, but analysis suggests that it
offers benefits to the very elderly high-
risk patient who is looking for signif-
icant symptomatic improvement that is
not available from medical therapy
alone. Table 2 shows informal guide-
lines currently used by our institutions
to select patients suitable for BAV.
Mechanisms of Dilation
The effects of BAV on the aortic valve
are poorly understood, but several
mechanisms are likely. The most com-
mon effect is intraleaflet fractures
within calcified nodular deposits.
These represent leaflet hinge points
and may increase flexibility within the
calcified aortic root to improve valve
opening. Other possible mechanisms
include scattered leaflet microfrac-
tures, cleavage planes along collag-
enized stroma, and uncommon separa-
tion of fused leaflets. Enhanced
compliance of the rigidly calcified ad-
jacent aortic root, which may follow
BAV, may further contribute to greater
leaflet flexibility. That no single mech-
anism has been proved suggests insuf-
ficient data and leaves unanswered the
TABLE 1. Complications During or
Within 24 Hours After Valvuloplasty
Procedure
Complication n (%)
Death 17 (3)
Patients with any severe complication 167 (25)
Type of complication
Hemodynamic
Prolonged hypotension 51 (8)
CPR required 26 (4)
Pulmonary edema 19 (3)
Cardiac tamponade 10 (1)
IABP use 11 (2)
Acute valvular insufficiency
Aortic 6 (1)
Mitral 1 (0.1)
Cardiogenic shock 15 (2)
Neurological
Vasovagal reaction 36 (5)
Seizure 15 (2)
Transient loss of consciousness 4 (0.6)
Focal neurological event 13 (2)
Respiratory
Intubation 28 (4)
Arrhythmia
Treatment required 64 (10)
Persistent bundle-branch block 34 (5)
AV block requiring pacing 30 (4)
VF or VT requiring countershock 18 (3)
Vascular
Significant hematoma 44 (7)
Vascular surgery performed 33 (5)
Systemic embolic event 11 (2)
Transfusion required 136 (20)
Ischemic
Prolonged angina 9 (1)
Acute myocardial infarction 10 (1)
Other severe complications
Pulmonary artery perforation 1 (0.1)
Acute tubular necrosis 1 (0.1)
CPR indicates cardiopulmonary resuscitation;
IABP, intra-aortic balloon pump; AV, atrioventric-
ular; VF, ventricular fibrillation; and VT, ventricular
tachycardia. Nϭ672.
TABLE 2. Patients in Whom
Percutaneous Balloon Aortic
Valvuloplasty Should Be Considered
Patients with symptomatic AS and any of the
following:
Bridge to surgical AVR in hemodynamically
unstable patients
Increased perioperative risk,
STS risk score Ͼ15%
Anticipated survival of Ͻ3 y
Age in the late 80s or 90s and prefer BAV
over open thoracotomy
Severe comorbidities such as porcelain aorta,
severe lung disease, and others for which the
CV surgeon prefers not to operate
Severe and/or disabling neuromuscular or
arthritic conditions that would limit the ability
to undergo postoperative rehabilitation
AVR indicates aortic valve replacement; STS,
Society of Thoracic Surgeons; and CV, cardiovas-
cular.
e336 Circulation March 27, 2007
by guest on January 11, 2013http://circ.ahajournals.org/Downloaded from
5. question of novel strategies for valvu-
lar dilation.
Silver Linings to a
Dark Cloud
Several technical and procedural im-
provements are now available for
BAV that did not exist 20 years ago
when Cribier first described the
procedure.10a
Rapid ventricular pacing
(200 to 220 bpm) now arrests mechan-
ical systole to preserve balloon stabil-
ity across the aortic valve during infla-
tion. The Inoue balloon (typically used
for mitral valvuloplasty) improves im-
mediate post-BAV aortic valve area
compared with conventional and retro-
grade BAV.11 Enhanced valve opening
may be achieved through leaflet hyper-
extension into the broader aortic root
diameter. The “dumbbell”-shaped In-
oue balloon locks on the aortic valve
and can accomplish leaflet hyperexten-
sion with a rounded distal end without
overstretching the valve annulus en-
gaged by the narrower neck.12 Further-
more, inflation–deflation times are
faster, and given the required ante-
grade transvenous approach, peripher-
al arterial complications are less likely.
Immediate post-BAV valve area is af-
fected by pre-BAV severity and corre-
lated with improved hemodynamic
long-term follow-up.
Investigations suggest that repeat
balloon valvuloplasty in AS patients
across multiple age groups (59 to 104
years) may improve 3-year survival
rates over a single dilatation.13 Repeat
BAV can be performed without addi-
tional complications. Most patients
have symptomatic relief for a year or
more. The value of symptomatic palli-
ation in this population cannot be un-
derstated. Minimizing the need for re-
peated hospitalizations for heart failure
has a large impact on quality of life for
these 80- to 95-year-old patients. Mis-
conceptions often include a higher-
than-reported rate of complications
such as perioperative stroke, post-
BAV aortic insufficiency, and myocar-
dial perforation. In a series of 86 pa-
tients Ն80 years of age, no myocardial
perforations occurred, and only 1 pa-
tient developed severe aortic regurgi-
tation.14 Only 1 of 86 patients suffered
stroke, and the overall periprocedural
mortality was 2.2%. Data from our
group show successful simultaneous
coronary stenting with BAV in 11
patients (mean age, 87 years; range, 79
to 99 years) between July 2003 and
May 2006 without complications or
in-hospital mortality (unpublished
data, Minneapolis Heart Institute BAV
registry). These data represent a favor-
able trend that is important given the
incidence of severe coronary artery
disease in these patients of 50%.
Valvular Restenosis and
Prevention
External Beam Radiation
The Radiation Following Percutaneous
Balloon Aortic Valvuloplasty to Pre-
vent Restenosis (RADAR) pilot trial
suggests that external beam radiation
may significantly reduce restenosis.
Restenosis in the RADAR pilot study
was 20% at 12 months in a population
with an average age of 89 years, sug-
gesting utility in elderly patients.15
This surprising benefit may occur
through the previously demonstrated
ability of external beam radiation ther-
apy to limit the formation of scar tissue
and heterotopic ossification previously
reported in restenotic aortic valves.
Potential for Transcatheter
Implantation and
Antirestenotic Drug Therapy
Percutaneous heart valve implanta-
tion with stent-based valves has been
performed in initial feasibility stud-
ies in inoperable patients with severe
AS. Immediate and early clinical im-
provement has been achieved in
small patient numbers with this tech-
nique. BAV will play a crucial role
in preparing the stenotic aortic valve
for the prosthetic implantation. Fur-
ther device improvements and long-
term follow-up are required in these
novel implantation devices before
premarket approval is obtained.
Antirestenotic drug therapy after
BAV has not been attempted, but pre-
clinical studies to prevent calcification
have been investigated in surgical set-
tings. Because drug-eluting stents have
replaced brachytherapy in the manage-
ment of coronary artery disease and
restenosis, local drug elution into di-
lated aortic valves may be possible, in
theory, to prevent restenosis after BAV
or work primarily to stimulate bone
regression.
Conclusions and Summary
Aortic valvuloplasty strategies should
be reevaluated, given the enhanced
knowledge of vascular and valvular
biology that permits targeted therapy
to prevent restenosis and to delay or
reverse valve mineralization. The in-
creasing numbers of poor surgical can-
didates in the expanding very elderly
population mandate less invasive
methods such as BAV to improve
quality of life. The time has arrived for
balloon aortic valvuloplasty to be re-
visited, and a resurgence of this proce-
dure is becoming possible through im-
proved knowledge and refined
transcatheter device developments.
The patient presented in this Clini-
cian Update needs to be followed up
regularly to monitor for evidence of
restenosis. If restenosis of the aortic
valve occurs and is clinically signifi-
cant, a repeat BAV can be performed.
Disclosures
None.
References
1. Kolh P, Kerzmann A, Lahaye L, Gerard P,
Limet R. Cardiac surgery in octogenarians:
peri-operative outcome and long-term
results. Eur Heart J. 2001;22:1235–1243.
2. Edwards MB, Taylor KM. Outcomes in
nonagenarians after heart valve replacement
operation. Ann Thorac Surg. 2003;75:
830–834.
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