High Risk Left Main PCI with Impella support In Post-TAVR patient

High Risk Left Main PCI with Impella support In Post-TAVR patient

Abdelkader Almanfi, MD Interventional Cardiology Fellow Texas Heart Institute

No financial disclosure related to this presentation

Disclosures

A 55 year old female (Jehovah's Witness) was referred to us for TAVR

PMH of severe symptomatic aortic stenosis, cardiomyopathy S/P ICD implantation and Hodgkins Lymphoma s/p Radiation and Chemotherapy.

Clinical Presentation

Coronary Angiogram prior to TAVR

Coronary Angiogram prior to TAVR

Ascending Aortogram

Due to her high surgical risk, she underwent successful transfemoral TAVI with 26 mm CoreValve.

Partially deployed CoreValve

- Uncomplicated post TAVR course. - No significant PVL or CHB- She was discharged home next day

4 months later

she presented to us with ACS --- chest pain and shortness of breath and elevated troponin.

EKG showed new onset left bundle branch block.

2 D Echo showed normally functioning aortic prosthesis with no significant PVL or significant gradient, the Dimensionless Index DI was 0.55 Also, Echo showed evidence of LV function deterioration with EF of 20% from previously known EF of 35%.

She was taken to the Cath lab and underwent coronary angiogram with left main IVUS that showed moderately calcified with severe stenosis with MLA 3.2 sq. mm

hemodynamic support was used because of Low EF, ACS, unprotected Left main lesion and h/o recent TAVR ----> High risk PCI

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Procedure tech.Impella CP was placed in the left CFA, 7 Fr right CFA for PCI access, both sides were pre-closed IV Heparin was used for full anticoagulation The patient was preloaded with Ticagrelor 180 mg7B 3.5 guide catheter, 0.014 Choice Floppy wire, Emerge 2.5 x12 balloon followed by 2.5x10 Flextome cutting balloon3.5x16 Promus stent into the LMpost dilated with 3.75x15 NC emerge balloon.

IVUS LM

Pre-dilatation with 2.5 x16 Emerge

LM PCI using Impella CP for hemodynamic support was done using 3.5x16 mm Promus premier stent

IVUS Post Stenting

3.5x16 Promus Premier stent

Post dilated with 3.75 x15 NC emerge

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Excellent results was confirmed with angiography and IVUS

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Post-op course & follow upThe Impella was removed without complications and the patient was discharged home after two days post procedure.

6 months follow up, patient was seen recently in the outpatient clinic, doing well, still on regular meds for heart failure EF 40%

DAPT with ASA and Ticagrelor with no reported bleeding issues, we decided for lifelong duration

Learning points from this case:

TAVR patient needs close follow up, readmission can be for multiple reasons including CHF, ACS and cardiac arrhythmiasWe are reporting the first use of Impella after TAVR for high risk PCIImpella can be safely used for high risk PCI or cardiogenic shock even in patient who underwent TAVR procedure/aortic bioprosthetic valve.

Thank you