2019 Scientific Sessions

Title Rescue Impella support during transcatheter aortic valve replacement Introduction Transcatheter aortic valve replacement (TAVR) for aortic stenosis in the setting of severely reduced left ventricular function and recent cardiac arrest poses a significant clinical challenge. This case demonstrates the role of temporary mechanical circulatory support as a bailout strategy which may be utilized in extremely high risk patients. Clinical Case A 56 year old male smoker with no other medical history presented with dyspnea and recurrent exertional syncope to an outside hospital emergency department. Shortly after presenting he suffered cardiac arrest requiring CPR, intubation, and initiation of vasopressors. Transthoracic echocardiogram demonstrated severe systolic dysfunction, EF 5-10% with global hypokinesis, moderate aortic regurgitation, critical aortic stenosis with valve area 0.54 cm2, mean gradient 38 mmHg, and peak velocity 3.9 m/s. CT chest showed bicuspid aortic valve, Sievers 0, and adequate bilateral iliofemoral access. Coronary angiography showed only nonobstructive disease. His STS risk score was 17% so he was referred for TAVR and transferred to a higher level of care. He was subsequently taken to the cardiac cath lab. In light of his severely reduced LV function and recent cardiac arrest bilateral large bore arterial sheaths were placed in anticipation of needing mechanical circulatory support if he were to decompensate after valve predilation which was required for his bicuspid valve. A 16F sheath was placed in the right CFA and 13F sheath was placed in left CFA. An 018 platinum wire was then advanced into the LV. Predilation was performed with an 18 mm Trueflow balloon with gentle pacing at only 90 bpm; however, immediately after balloon inflation the patient suffered sudden hemodynamic collapse and subsequent cardiac arrest. CPR was initiated without achieving ROSC. Impella 2.5 was then rapidly placed into the left ventricle over the 018 wire via the second access site. After 5-10 minutes systolic blood pressure improved to 110s-130s. The Impella was then swapped inside the body at the aortic arch and a 29 mm Medtronic Evolut Pro valve was deployed at native rate followed by postdilation. Hemodynamics, root angiography and transthoracic echocardiogram revealed a well placed and well seated valve with no evidence of significant aortic regurgitation and mean gradient of 2 mmHg. He was placed on guideline directed medical therapy and later discharged with a LifeVest external defibrillator. At 3 week followup he was doing well with NYHA I symptoms, EF 35%, and mean gradient of 4 mmHg. Discussion TAVR may be performed using temporary mechanical circulatory support in patients at the highest risk for potential complication. Success is predicated on careful planning and anticipation of potential problems. Sudden hemodynamic collapse is an emergent complication during TAVR which may be foreseen in patients with cardiomyopathy and ejection fraction <10-20%. Impella is a tool which may be implemented rapidly as a bailout strategy after appropriate planning in TAVR cases complicated by cardiogenic shock and cardiac arrest.