The hemodynamic and clinical results following 25 percutaneous aortic valvuloplasty (PAV) procedures on 24 patients are reported. The mean aortic gradient decreased from 66 +/- 23 to 40 +/- 15 mm Hg (p less than 0.001) and the mean valve area increased from 0.5 +/- 0.17 to 0.7 +/- 0.26 cm2 (p less than 0.001). Although the aortic gradient determined by both Doppler and direct measurement correlated well before PAV, the Doppler gradients determined 24 +/- 48 hours after the procedure were significantly higher than the directly measured gradients at the time of PAV. Ninety-two percent of patients were New York Heart Association class III or IV before PAV. Of the remaining 12 patients, 6 (50%) were classified as class II, 2 (17%) were class III, and 4 were (33%) class IV. Necropsy examination of the patient who died shortly after valvuloplasty revealed localized hematoma and tear in the anterior mitral valve leaflet. Smaller initial valve areas yielded smaller valve areas after PAV. Patients with greater valve areas following PAV showed greater functional improvement. Only 7 patients (29%) had at least 1 functional class improvement at the final follow-up. PAV can be performed relatively safely in elderly, moribund patients, although sustained improvement of functional status is not common. In this population, PAV should be limited to patients severely symptomatic in whom surgery is not an acceptable option.