Editor-In-Chief: C. Michael Gibson, M.S., M.D. ; Joanna J. Wykrzykowska, M.D.; Associate Editor(s)-In-Chief: Mohammed A. Sbeih, M.D. 
Although surgical aortic valve replacement is the mainstay of treatment of aortic stenosis as it improves both symptoms and life expectancy, some patients may not be surgical candidates due to comorbidities, and minimally invasive treatment such as percutaneous aortic balloon valvotomy (PABV) maybe an alternative to surgery as a palliative strategy. PABV is a procedure in which 1 or more balloons are placed across a stenotic valve and inflated to decrease the severity of aortic stenosis. This is to be distinguished from transcatheter aortic valve implantation (TAVI) which is a different method that involves replacement of the valve percutaneously.
- ACC/AHA guidelines concluded that percutaneous aortic balloon valvotomy (PABV) is not a substitute for aortic valve replacement in adults. In adults with severe calcific AS who are not good candidates for this procedure as there is high restenosis rate (more than 10% of cases) and high risk of complications. Clinical deterioration occur within 6 to 12 months in most patients, and that is why balloon valvotomy is not a substitute for aortic valve replacement surgery. The procedure can be used in children and young adults with congenital, noncalcific AS.
Percutaneous Aortic Balloon Valvotomy (PABV) Technique
- After preparing the patient, a guide wire is inserted through the femoral artery into the aorta (retrograde technique). 8 French femoral sheath can usually accommodate a 20 mm balloon and minimizes vascular complications. Alternatively two 6 Fr sheath from bilateral femoral approach and two smaller balloons can be used. The latter may be necessary in elderly female patients with concomitant peripheral vascular disease.
- 0.035” straight wire is commonly used to cross the valve and advance via pig-tail or Amplatz catheter; right heart catheterization is done and transaortic gradient is typically measured pre-procedure. The 0.035” wire is then exchanged for a stiffer 0.038” Amplatz exchange length wire with the tip shaped into a pig-tail shape so as not to injure the left ventricle.
- A long sheath is introduced over the guide wire, through the sheath a Mansfield balloon is introduced and 20–23 mm X 6 cm balloon is advance over the wire and positioned to straddle the aortic valve.
- The balloon is manually inflated with a 60 cc syringe containing diluted contrast (slowly). Meticulous control of balloon position must be maintained at all times by backward traction on the balloon to prevent jumping forward and injuring/perforating the left ventricular apex.
- If there is difficulty in maintaining the balloon across the aortic valve during inflation, temporary ventricular pacing at high rate can reduce the cardiac output and give stability to the balloon.
- Balloon is deflated and the transvalvular gradient reassessed for success of the procedure. Repeated dilatations can be given if necessary.
- The balloon should be de-aired and filled with dilute contrast to avoid the chance of air embolism in case of balloon rupture during dilatation.
- Immediately after the procedure a moderate reduction in the transvalvular pressure gradient is usually observed. The aortic valve area after the procedure rarely exceeds 1.0 cm2 but an early symptomatic improvement is usually observed.
- Patient survival after repeat PABV is higher than that of untreated patients.
- Vascular complications are most common thus suture (Perclose) or Angioseal closure after the procedure in this tenuous patient population is preferable.
- It follows that attention to meticulous access technique is mandatory.
- Antegrade approach ie venous access with transseptal approach can be done in select patients, however, hemodynamic effects of mitral valve incompetence as a stiff wire is placed across the mitral valve are often poorly tolerated; mitral valve injury has been reported in this approach.
- There is a small but significant risk of development of aortic regurgitation as a result of the procedure which can lead to pulmonary edema.
- The balloon may rupture while dilation of a calcified valve is performed.
2008 Focused Update Incorporated Into the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease and the Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)
Recommendations for Aortic Valve Repair/Replacement and Aortic Root Replacement (DO NOT EDIT)
|| *Consider lower threshold values for patients of small stature of either gender.
Aortic Balloon Valvotomy Indications (DO NOT EDIT) 
Aortic Balloon Valvotomy Indications in Adolescents (DO NOT EDIT) 
|| * Gradients are usually obtained with patients sedated. If general anesthesia is used, the gradients may be somewhat lower.
- ↑ 1.0 1.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.". J Am Coll Cardiol 52 (23): e1-121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
- ↑ 2.0 2.1 2.2 Bonow RO, Carabello BA, Chatterjee K, et al. (October 2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B (August 2006). "ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons". Journal of the American College of Cardiology 48 (3): e1–148. doi:10.1016/j.jacc.2006.05.021. PMID 16875962. Retrieved on 2012-11-12.