Percutaneous aortic valve replacement: valvuloplasty studies in vitro

Objective: Valvuloplasty of the aortic valve is currently used in selected patients for severe calcified aortic valve disease, but clinical effectiveness is low and complication rate remains high. In this study, the total particle load after valvuloplasty and the embolization risk of calcific debris into the coronary arteries was analyzed in an in vitro model. Methods: Three highly calcified human aortic leaflets have been sutured into a porcine annulus (N = 9). Both coronary arteries were separated and each was anastomized to a silicon line, which was drained off into a measuring beaker. Then valvuloplasty was performed (Thyshak II, 20 mm, 1.5 atm). After removal of the balloon, 100 ml of sodium chloride solution irrigated the ascending aorta. After passing through the separated coronary arteries, the solution was filtered (filter size 0.45 mu m), dried, and the total amount of particles was analyzed microscopically. Results: Nine experiments were analyzed. After valvuloplasty, all hearts showed a median of 18 particles larger than 1 mm in the coronary arteries (range 0-307). The amount of particles smaller than 1 mm was 6574 (median, range 2207-14200). In five cases, coronary arteries were completely occluded by bulky particles. Conclusion: This study demonstrated a large amount of calcific particles after valvuloplasty with a consequently high risk for coronary embolic events in case of highly calcified aortic valves. In times of valvuloplasty rediscovering as part of transcatheter valve implantation, the risk of embolization should be taken into consideration and filtering techniques have to be developed. (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B. V. All rights reserved.