[Severe aortic stenosis and cardiogenic shock: a therapeutic challenge]

Successful Urgent TAVI for Critical Aortic Valve Stenosis after ECMO Implantation

Transcatheter aortic valve implantation (TAVI) has evolved to be the treatment of choice for patients with severe aortic stenosis and high perioperative risk. Cardiogenic shock is one of the most severe complications during the TAVI procedure, especially as the prognosis of cardiogenic shock secondary to aortic stenosis is very poor. This situation can be challenging, while extracorporeal membranous oxygenation (ECMO) can be a treatment option. Here, we reported on an 88-year-old female patient who had been diagnosed as non-ST-elevation myocardial infarction (NSTEMI) and critical aortic valve stenosis (AS) with a logistic Euroscore of 25%. Percutaneous coronary angioplasty (PCI) was performed smoothly and developed tachy-brady arrhythmia of atrial fibrillation then cardiac arrest at the beginning of the TAVI procedure. A v-a ECMO was installed at her left femoral side. Afterward, the TAVI procedure was completed accordingly; her consciousness recovered and Levosimendan therapy enhanced her left-ventricular ejection fraction (LVEF) from 22% to 40%. Five days after TAVI, ECMO was replaced by intra-aortic balloon pumping (IABP) and it was removed 3 days later. A minor complication of this therapy, e.g., muscular weakness in her left leg, was noted. The patient underwent rehabilitation for about 2 months, and was discharged from hospital with a wheel chair and clear consciousness. At the 24 month follow-up she was in good recovery and was able to walk upstairs to the second floor again. Our experience suggests that one indication of prophylactic use of ECMO is for patients with an unstable hemodynamic condition.

Use of extracorporeal membrane oxygenation as a bridge to transcatheter aortic valve replacement in a patient with aortic stenosis and severe coronary artery disease: a case report

Background

Patients with severe aortic stenosis (AS) often present with multiple comorbidities and suffer from critical coronary artery disease (CAD). Transcatheter aortic valve replacement (TAVR) has become the therapy of choice for moderate to high-risk patients. Venoarterial extracorporeal membrane oxygenation (v-a-ECMO) offers the possibility of temporary cardiac support to manage life-threatening critical situations.

Case summary

Here, we describe the management of a patient with severe AS and CAD with impaired left ventricular ejection fraction (LVEF). We used v-a-ECMO as an emergency strategy in cardiogenic shock during a high-risk coronary intervention to stabilize the patient, and as a further bridge to TAVR.

Discussion

Very high-risk patients with severe AS are unlikely to tolerate the added risk of surgical aortic valve replacement. Using ECMO may help them to benefit from TAVR as the only treatment option available.

Balloon Aortic Valvuloplasty in Patients Admitted for Cardiogenic Shock with Severe Aortic Stenosis: A Retrospective Analysis of 14 Cases

Introduction Balloon aortic valvuloplasty (BAV), introduced in 1986, quickly lost its wide adoption due to the high incidence of restenosis after the procedure and due to improved skills in transcatheter aortic valve implantation (TAVI). It has seen a re-emergence in the last few years as bailout therapy in critical care patients presenting with cardiogenic shock (CS) and severe aortic stenosis (AS), who are temporarily unable to tolerate such a procedure as TAVI or surgery for valve replacement. Methods We did a retrospective analysis of every BAV performed between January 1, 2008, and November 11, 2018, in our hospital and identified those admitted to the cardiac intensive care unit (CICU) due to cardiogenic shock with severe aortic stenosis, as defined in the European Society of Cardiology Guidelines. Procedures were categorized as emergent (within 24h after the decision to intervene) and urgent (24h after the decision was made but before discharge). Results During this period, of 98 BAV performed, 14 were performed on patients with CS with severe AS, nine of them being emergent. The patients' mean age was 76.2±7.2 years, with 6 (43%) of them being female. On the day of BAV, the mean Euroscore II and sequential organ failure (SOFA) were, respectively, 19±7% and 8.0±2.4 in emergent cases and 11±5% and 4.8±2.9 in urgent cases. In patients deemed emergent, there was a tendency for a decrease in SOFA in the days following the procedure, although not statistically significant (p>0.05). Clinically significant aortic regurgitation did not occur in any patient, neither were there any major post-procedure complications. Thirty-day mortality was 33% in emergent cases and 0% in urgent cases. In emergent cases, four were later submitted to TAVI and one had surgery for aortic valve replacement surgery. Only one patient in the urgent group was regarded as a candidate for TAVI. Discussion and conclusion Emergent cases presented with higher scores of severity and procedure risk and had greater mortality. In this group, a greater proportion of survivors was later deemed fit for definite procedures. This highlights that presenting status does not seem to influence the prognosis of those extremely high-risk patients once the acute event is promptly treated. Nevertheless, the low sample size precludes generalization of the findings. BAV as bailout treatment may be safe in patients presenting with CS and severe AS, allowing patient survival for elective definitive treatment.

Aortic stenosis complicated by cardiogenic shock treated by transcatheter aortic valve replacement with extracorporeal membrane oxygenation: A case report

RATIONALE

Cardiogenic shock secondary to aortic stenosis (AS) is a challenging problem owing to the high mortality associated with treatment, and successful treatment of such patients has been rare.

PATIENT CONCERNS

A 77-year-old man presented with exercise intolerance and progressive exertional dyspnea and chest pain. The patient was suffered from cardiogenic shock after percutaneous coronary intervention.

DIAGNOSIS

He was diagnosed by transthoracic echocardiography (TTE) and coronary angiogram. His main diagnose was AS and coronary artery disease.

INTERVENTION

The patient received venoarterial extracorporeal membrane oxygenation (VA-ECMO) and transcatheter aortic valve replacement (TAVR).

OUTCOME

As of the 5-month follow-up, the patient was well, and capable of basic independent living. The TTE suggested that the left ventricular end-diastolic volume had decreased from 66 to 45 mm and the left ventricular ejection fraction had risen from 20% to 50%.

LESSONS

Patients with cardiogenic shock secondary to AS are very difficult to treat medically. ECMO with TAVR may be a reasonable strategy.