Successful emergent transcatheter aortic valve implantation and left ventricular unloading by Impella in a patient with severe aortic stenosis who experienced cardiogenic shock after primary percutaneous coronary intervention for ST-elevation myocardial infarction: a case report

Abstract

Background: Determining the treatment strategy for cardiogenic shock following ST-elevation myocardial infarction in a patient with severe aortic stenosis remains challenging and is a matter of debate.

Case summary: An 84-year-old man with chest pain was transferred to our institute and subsequently diagnosed with ST-elevation myocardial infarction and Killip class III heart failure. The patient was intubated, and urgent coronary angiography revealed severe tandem stenosis from the proximal to mid-left anterior descending coronary artery. We performed a primary percutaneous coronary intervention (PCI) and deployed drug-eluting stents from the left main trunk to mid-left anterior descending coronary artery. Although the procedure was successful, the patient went into cardiogenic shock a few hours later. Transthoracic echocardiography revealed low cardiac function and severe aortic stenosis. We decided to perform transcatheter aortic valve implantation using a self-expandable valve, followed by the insertion of a left ventricular assist device. The combination of procedures achieved haemodynamic stability.

Discussion: It is difficult to treat cardiogenic shock that develops in patients with severe aortic stenosis and ST-elevation myocardial infarction. This case report demonstrates that combined transcatheter aortic valve replacement using a self-expanding valve and left ventricular assist device placement can be safe and effective after a primary PCI.

Keywords: Aortic stenosis; Cardiogenic shock; Case report; Impella CP; ST-elevation myocardial infarction; Transcatheter aortic valve implantation.

Figure 1

(A and B) Coronary angiography shows severe stenosis from the proximal to mid-left anterior descending coronary artery. (C and D) Drug-eluting coronary stents are deployed from segments 5–7.

Figure 2

(A) Transthoracic echocardiography shows severe aortic stenosis with a peak velocity of 4.2 m/s and an aortic valve area of 0.5 cm². (B and C) Electrocardiography-gated cardiac computed tomography demonstrates severe calcification of all aortic leaflets. Contrast computed tomography demonstrates the full body access route.

Figure 3

(A and B) Balloon aortic angioplasty was performed using a 20-mm Inoue balloon without rapid pacing, followed by deployment of a 29-mm CoreValve Evolut PRO. (C and D) The Impella CP guidewire for the left ventricle was placed onto the leaflets of the CoreValve Evolut PRO to confirm that it was in proper position; the outlet of the Impella CP device was at the proper distance from the tip of the CoreValve.