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High-risk PCI and TAVI: A complex case with balloon aortic valvuloplasty and Impella support
Session:
Sessão Speaker’s Corner - Casos clínicos desafiantes… em Cardiologia de Intervenção
Speaker:
Pedro Garcia Brás
Congress:
CPC 2022
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
25. Interventional Cardiology
Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Pedro Garcia Brás; Inês Rodrigues; Tiago Mendonça; José Viegas; Alexandra Castelo; Rúben Ramos; António Fiarresga; Duarte Cacela; Rui Cruz Ferreira
Abstract
<p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The authors present the case of an 85-year old female patient, with known history of left main (LM) and 3-vessel coronary disease, severe aortic stenosis (AS), heart failure (HF) with midly reduced ejection fraction (45%), and stage 4 chronic kidney disease (CKD). </span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The patient was admitted for a non ST-segment elevation myocardial infarction (NSTEMI) with acute decompensated HF (ADHF). With a complex coronary anatomy and major comorbidities, this case was considered in Heart Team discussion to be too high risk for either cardiac surgery or percutaneous coronary intervention (PCI), and conservative management was proposed.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">However, 2 months later, the patient had 2 hospital admissions for NSTEMI and ADHF and thus the decision to proceed with coronary and valvular percutaneous intervention was made. Baseline coronary angiography (Figures) showed obstructive lesions of the LM, mid left anterior descending artery (LAD), proximal circumflex artery (LCX), 1<sup>st</sup> obtuse marginal (OM) and an occluded nondominant right coronary artery.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The first step was to perform balloon aortic valvuloplasty (BAV) with a 20 mm balloon, which was successful with only mild residual regurgitation. Secondly the mid LAD obstruction was addressed, with implantation of a 3x18 mm drug-eluting stent (DES). Shortly after LAD PCI, hypotension developed. Despite promptly initiated IV fluids and vasopressors, hypotension recurred with impaired peripheral perfusion, and a left femoral Impella CP assist device was implanted.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">With the added cardiac output from the assist device, hemodynamic stability was achieved. PCI proceeded with implantation of a 3.5x30 mm DES in the LCX/LM, followed by proximal optimization technique (POT) of the LM with a 4 mm balloon. Balloon angioplasty of the 1<sup>st</sup> OM lesion was also performed. Finally, PCI of the proximal LAD obstruction was successful, with implementation of the TAP technique.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">After PCI was concluded, the Impella assist device was retrieved and a transfemoral balloon-expandable transcatheter aortic valve implantation (TAVI) was successfully performed (23 mm), with no hemodynamic instability. A final angiography showed no residual aortic regurgitation and no coronary ostiae obstruction.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">The patient developed transient complete heart block during TAVI, and later in the ICU left-bundle branch block with increasing 1<sup>st</sup> degree AV block, leading to implantation of a permanent pacemaker. Due to the high contrast load in a patient with CKD, temporary renal replacement therapy was necessary, with further recovery of renal function and urine output, and the patient was safely discharged 10 days after the intervention.</span></span></p> <p><span style="font-size:11pt"><span style="font-family:"Calibri",sans-serif">This clinical case details the possibility of balloon aortic valvuloplasty (BAV) before performing high-risk PCI in patients with severe AS. Hemodynamic support with the Impella left ventricular assist device was crucial, allowing for high-risk LM and 2-vessel PCI before TAVI.</span></span></p>
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