Left Ventricular Rapid Pacing in Balloon Aortic Valvuloplasty (BAV): The Novel Refinement of an Old Technique

Abstract

Balloon aortic valvuloplasty (BAV) is experiencing increased use due to the rise of transcatheter aortic valve replacement (TAVR), particularly after the results of the PARTNER 3 trial demonstrated positive outcomes in low-risk aortic stenosis patients. We revisit a particular technical aspect of BAV; namely, the method of pacing. Traditionally, pacing procedures for BAV prior to balloon inflation employ the use of a right-sided temporary pacing lead, whose insertion process contributes to greater vascular complications and longer overall procedural times. An alternative, older method where rapid pacing of the left ventricle (LV) is performed with the use of a guidewire enables consistent pacing and reduces procedural time without the need for additional pacing lead insertion. We describe a case where LV pacing was done via the use of an LV parked guidewire, facilitating successful BAV in a patient with a permanent pacemaker.

A resurgence in the use of BAV has occurred in recent years due to its complementary application with transcatheter aortic valve replacement (TAVR). First developed in 1986 by Alain Cribier, BAV initially fell out of use as the sole alternative to aortic valve surgery due to its high rates of valve restenosis and symptom recurrence, as well as the lack of established mortality benefit when used alone. However, BAV has found utility once again after Cribier revisited its use in 2002 during the initial development of the TAVR procedural protocol.¹ At present, BAV is used mainly as an additional procedural element for deploying the transcatheter valve, transcatheter valve sizing, and post valve deployment enhancement in TAVR.¹ BAV still holds a recommendation due to its utility when used alone as a temporizing or bridging modality for severe aortic stenosis in hemodynamically unstable patients.^2,3

The performance of BAV requires the employment of temporary ventricular pacing, done in order to transiently decrease cardiac output and minimize displacement forces exerted on the valvuloplasty balloon during inflation.^1,5 Temporary ventricular pacing is traditionally facilitated via the insertion of a temporary pacing wire (TPW) through the femoral, jugular or subclavian veins, then advanced into the right ventricular apex. However, this maneuver may be difficult in certain emergent clinical scenarios. Performing a TPW insertion increases procedure time and exposes the patient to potential vascular complications, pericardial complications, and infections. In addition, certain patients may have undergone prior permanent pacemaker insertion (PPI). Several case studies have documented successful BAV and TAVR performance after re-programming pacemakers for overdrive pacing; however, it should be noted that such techniques do not have any previously studied or validated protocols.^6,7 Rapid LV pacing has been seen to be feasible in BAV, as the incidence of untoward intraprocedural events requiring PPI is significantly lower than TAVR.⁸ It was under this rationale that proponents supporting the use of left ventricular pacing have proposed a revival of this old method. The employment of left ventricular pacing was initially described in pediatric patients undergoing balloon valvuloplasty, but fell out of use after the institution of TAVR protocols that required mandatory TPW insertion for anticipated heart blocks, a complication seen more frequently in the earlier generation of TAVR devices.⁶ The lack of use of left ventricular pacing is unfortunate, as numerous experiences with its use have proven to offer several advantages, along with greater procedural ease.^6,8 Herein, we describe a case where left ventricular pacing facilitated successful BAV in a patient with a permanent pacemaker.

Clinical Case

An 80-year-old Filipino male was admitted with complaints of progressive dyspnea noted several hours prior to admission. The patient’s past medical history included severe calcific aortic stenosis (aortic valve area [AVA] of 0.8 cm²), multi-segmental wall motion abnormality with depressed left ventricular systolic function (ejection fraction [EF] of 45%), and dual-chamber pacemaker insertion four years prior for sick sinus syndrome. The patient was further noted to have frequent readmissions for recurrent pulmonary edema. At the emergency department, the patient was noted to be tachycardic (heart rate 103 bpm), tachypneic (28 cpm) with desaturation noted (82%) at room air. Physical examination revealed crackles on all lung fields. The patient was treated as a case of acute decompensated heart failure, was subsequently intubated, and admitted to the hospital’s medical intensive care unit (mICU). During the course of the patient’s mICU admission, he was eventually extubated on the third hospital day, but due to recurrent episodes of flash pulmonary edema and refractory failure symptoms, was later reintubated. Further complications, including the eventual development of acute kidney injury necessitating renal replacement therapy, later developed. The patient was then advised urgent BAV with the intent of bridging to TAVR.

After the patient and his family consented, the procedure was carried out. Intraoperative transesophageal echocardiography (TEE) revealed pre-procedure baseline findings of severe aortic stenosis (AVA 0.58 cm²; Vmax 4.39 m/s; peak gradient 77 mmHg, mean gradient 49 mmHg) with depressed LV systolic function (EF of 22%) (Figures 1-2). Bilateral transfemoral access was achieved via surgical cutdown with 6 French sheaths inserted. Coronary angiography showed moderate single-vessel coronary artery disease of the left anterior descending artery (LAD). A regular straight tip .035-inch guidewire was passed through the right sheath and advanced across the aortic valve. The guidewire was later swapped out for an Amplatz stiff wire, utilized to guide an AL1 catheter (Cordis, A Cardinal Health company) across the aortic valve. The Amplatz wire was changed to a pre-curved .035-inch x 260 cm Confida Brecker guidewire (Medtronic), which was subsequently advanced until its tip was parked in the LV apex (Figure 3). The 6 French sheath was changed to a 12 French sheath. A 20 mm x 4.0 cm percutaneous transluminal valvuloplasty catheter was successfully placed, with the mid-balloon positioned at the aortic valve. The distal tip of the Confida Brecker wire was then scraped and used for rapid LV pacing at 120 bpm. Good capture was noted and successful balloon valvuloplasty was carried out (Figure 4). Successful reduction of the severe aortic stenosis was noted, with a 50% decrease of peak aortic to LV gradient from 80 mmHg to 40 mmHg (Figure 5). Repeat TEE readings revealed decreased gradient across the aortic valve (AVA 0.9 cm²; Vmax 3.91 m/s; peak gradient 61 mmg; mean gradient 33 mmHg). The patient remained stable throughout the procedure, and was eventually extubated and discharged improved with plans for TAVR.

Discussion

Left ventricular pacing was first introduced in 2007 as a novel method to facilitate the easier performance of BAV, without the need for additional TPW or additional programming of existing pacing systems, for which there are still no standard protocols. Left ventricular pacing was performed on pediatric patients with congenital aortic stenosis, with noted reduced vascular complications, decreased incidence of aortic insufficiency, and shorter fluoroscopy time.⁹ A case series conducted on adults that was published a year later (2008) noted similar positive experiences, with pacing efficacy equal to that of standard right ventricular pacing, except with greater ease of technique performance.¹⁰ However, as previously noted, the use of a left ventricular pacing technique fell out of use due to the early TAVR protocols requiring TPW insertion for anticipated arrhythmias and heart blocks seen more frequently in early generation valves, as well as to ensure appropriate rapid pacing.

Other than the initial cases described in 2007, subsequent reports on the performance of this novel technique remain sparse, with only three other manuscripts recently published on left ventricular pacing. The first is a case report similar to our own, describing a 79-year-old male with 3-vessel coronary artery disease and a permanent pacemaker who underwent percutaneous coronary intervention and BAV with TAVR. An Amplatz extra-stiff guidewire with a custom pigtail shape was utilized for rapid ventricular pacing, with capture noted. Similar to our case, the procedure was successfully completed with no complications.¹⁰ Second is a study by Faurie et al, conducted in 38 patients undergoing BAV alone and 87 patients undergoing TAVR, that demonstrated reduced procedural time, reduced incidence of vascular complications and cardiac tamponade, and with successful stimulation in all recorded cases in the study. Faurie aptly summarized the study group’s support of this technique, describing it as “the next step in the additional enhancement of TAVR [protocols].”⁶ The final publication is a second study, published by Hilling-Smith et al, conducted among 76 patients undergoing BAV alone and 110 patients undergoing BAV with TAVR. It documented similar findings: consistent pacing, reduced procedural time, reduced vascular complications, and a potential for early patient mobilization. However, limitations are also appropriately described, which include the potential loss of pacing capabilities should the dual-purpose LV pacing wire require removal, such as in cases of severe aortic regurgitation or mitral apparatus involvement and complications, as well as the potential for “crossover” to mandatory pacemaker insertion which, although rare, is still a notable occurrence in the study.¹¹

Overall, the benefits of LV pacing are numerous and far outweigh the potential complications. Of interest is an upcoming global study examining the efficacy of LV pacing in TAVR utilizing the valve delivery guidewire.¹² We believe our case to be the first in the Southeast Asian region to document successful implementation of LV pacing in BAV, and we hope to raise awareness of this novel technique that has potential to enhance the performance of BAV.

We would like to emphasize that the feasibility of performing LV pacing in our case was thoroughly discussed with the intervention team prior to its performance. Factors that contributed to the decision to perform LV pacing in this patient included: (a) the patient’s profile, particularly the absence of sinoatrial (SA) node and atrioventricular (AV) conduction pathologies; (b) the decision to perform BAV alone as a bridge to TAVR at a later procedural date and; (c) the need for reduced procedural time, given the patient’s overall status. Pre-procedure precautions, such as ruling out pre-existing AV conduction pathologies, were done in order to minimize complications.

Conclusion

The authors describe the successful performance of BAV utilizing rapid LV pacing in an 80-year-old male with severe aortic stenosis admitted for recurrent failure symptoms. The performance of this older technique has proven to be feasible and effective in reducing procedural time, fluoroscopy exposure, and potential vascular complications. We fully support the wider use and development of this technique, but also recognize its potential limitations, especially in the presence of factors that may necessitate the need for permanent pacing in the future (i.e., co-existing conduction pathologies).  

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Keith Andrew L. Chan, MD, at keithachan@gmail.com.

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12. Groupe Hospitalier Mutualiste de Grenoble (Trial Sponsor). Direct Left Ventricular Rapid Pacing Via the Valve Delivery Guide-wire in TAVI (EASY TAVI). ClinicalTrials.gov Identifier: NCT02781896. Available online at https://clinicaltrials.gov/ct2/show/NCT02781896. Accessed November 25, 2019.