Resident Temple University Hospital philadelphia, Pennsylvania, United States
Disclosure(s):
Laya Manoj, MD: No financial relationships to disclose
Background: Severe bioprosthetic aortic stenosis and consequent cardiogenic shock carries high morbidity and mortality. Temporary mechanical circulatory support is increasingly used for high-risk structural interventions, but the role of ECPR to facilitate TAVR remains unclear. We describe a patient successfully treated with ECPR-supported TAVR using a multidisciplinary, bloodless medicine approach.
Methods: A 61-year-old man with prior 29 mm Edwards SAPIEN 3 TAVR, HFrEF s/p CRT-D, CAD s/p PCI to LAD, ESRD on hemodialysis, and chronic anemia presented with several weeks of worsening exertional dyspnea and orthopnea, consistent with acute decompensated heart failure. Transthoracic echocardiography demonstrated rapid progression to severe calcific bioprosthetic aortic stenosis compared to imaging three months earlier, with markedly elevated gradients (peak velocity 3.99 m/s; mean gradient 42 mmHg; Doppler velocity index 0.14). Transesophageal echocardiography confirmed severely restricted motion of the left and noncoronary cusps.
On hospital day two, hypotension and inability to tolerate ultrafiltration necessitated transfer to the ICU for inotrope-supported SCAI Stage C cardiogenic shock management. On day three, new-onset chest pain prompted coronary angiography, revealing 80% distal LAD in-stent restenosis, treated with a 3.5 × 20 mm Synergy drug-eluting stent. Despite revascularization, he progressed to SCAI Stage E shock with escalating vasopressor and inotrope needs. He experienced a PEA arrest and underwent emergent extracorporeal cardiopulmonary resuscitation (ECPR) with bedside peripheral VA-ECMO cannulation. Multidisciplinary evaluation determined he was not a surgical AVR candidate (STS risk 49%).
Outcome: With stabilization on VA-ECMO, the heart team proceeded with high-risk valve-in-valve intervention. On hospital day eight, the patient underwent successful transcatheter aortic valve replacement using a 29 mm Medtronic Evolut PRO+ implanted within the degenerated 29 mm Edwards SAPIEN 3 prosthesis. Hemodynamics improved significantly, with a final mean gradient of 8 mmHg and restoration of forward flow.
Following the procedure, he was gradually weaned from mechanical circulatory support and decannulated with preserved neurologic function. End-organ perfusion improved post-intervention. His recovery trajectory reflected effective integration of ECPR, multidisciplinary decision-making, and high-risk structural intervention in a complex patient with cardiogenic shock due to bioprosthetic valve failure.
Conclusion: A multidisciplinary team guided procedural planning and bloodless management for this Jehovah’s Witness patient with chronic anemia on ECMO and recent PCI. Despite complex vascular access, ECPR with peripheral VA-ECMO successfully enabled high-risk valve-in-valve TAVR for rapidly progressive cardiogenic shock due to severe bioprosthetic aortic stenosis.
