Interpretation of hemodynamic data during the procedure is based on measurement of transvalve pressure gradient and cardiac output with calculation of valve areas (Fig. 33.2) [3]. Most patients have an initial aortic valve area between 0.4 and 0.8 cm². Typical post-procedure results involve increases in valve area up to 0.9–1.2 cm². One standard definition of procedure success is a 50 % increase in valve area or a 50 % decrease in mean transvalvular pressure gradient.

Major complications of the procedure are vascular access complications, damage to the aortic valve, or cardiac perforation. Large vascular sheaths are used for either venous or arterial access. Bleeding complications can be common and transfusion is needed in 25 % of patients when manual compression is used for arterial hemostasis. Bleeding complications are minimized by the use of suture closure techniques following the procedure. Some patients have dramatic hypotension and left ventricular failure immediately following balloon inflations, which in some cases leads to fatality on the catheterization laboratory table. Permanent pacemakers for heart block are required in 1 % or 2 % of patients, especially if underlying bundle-branch block is present to begin with. Hospital mortality is 5–8 % in this elderly, highly sick patient population when BAV is done as primary therapy, and probably less when BAV is done as a bridge to TAVR [4].

An 84 year old man presents with CHF and is found to have aortic stenosis with a Doppler estimated aortic valve area of 0.6 cm². The transvalve mean and peak gradients are 54 and 76 mmHg, and left ventricular function is moderately depressed with ejection fraction 40 %. He has a history of CABG at age 70 and then again at age 78 years. The ECG shows atrial fibrillation with a rate of 85 bpm. Angiography shows a patent LIMA to LAD, patent native RCA, and occluded native and graft circumflex supply. In addition he has chronic kidney disease and recently diagnosed lung cancer.

His STS risk score is 16 % and due his untreated cancer and frailty he is felt not to be a candidate for TAVR. Thus, balloon valvuloplasty is an attractive palliative therapy. BAV was performed using the antegrade approach. Right femoral venous 6F access was obtained, and a 6F Closer S device was used to place a suture. Baseline right heart pressures were measured. A 14F sheath was placed. After transseptal puncture, baseline transaortic gradient was assessed & valve area calculated. A balloon flotation was passed from LA to LV, and then antegrade across the aortic valve into the descending aorta. A guidewire was passed through the balloon catheter and snared in the descending aorta. The transseptal catheter was exchanged for a Inoue 26 mm balloon. This was passed over the wire to the aortic valve and inflated once to accomplish valve dilatation. Final transaortic valve pressure gradients were measured and valve area calculated. The 14F venous sheath was removed with pre-placed suture closure. He was discharged from the hospital the next morning.