# Case Report: Balloon aortic valvuloplasty with subsequent Impella support as bridge therapy to transcatheter aortic valve replacement in cardiogenic shock with severe aortic stenosis

## TL;DR

This case report describes a treatment approach combining balloon aortic valvuloplasty and Impella support to stabilize patients with severe aortic stenosis and cardiogenic shock before aortic valve replacement.

## Contribution

The novel 'BAV-PELLA-TAVR' approach is introduced as a bridge therapy for high-risk patients with cardiogenic shock and severe aortic stenosis.

## Key findings

- Three patients with cardiogenic shock and severe aortic stenosis were successfully stabilized using balloon aortic valvuloplasty followed by Impella support.
- The BAV-PELLA-TAVR approach enabled subsequent interventions and reduced perioperative risks for transcatheter aortic valve replacement.
- Hemodynamic improvement was achieved in all cases, allowing for multidisciplinary evaluation and elective TAVR.

## Abstract

Cardiogenic shock (CS) with severe aortic stenosis (AS) is a drug-resistant hemodynamically unstable condition with high mortality. We report three cases of CS with severe AS that were successfully managed with balloon aortic valvuloplasty (BAV), followed by left ventricular (LV) unloading using Impella as a bridge therapy for transcatheter aortic valve replacement (TAVR). We call this therapeutic approach “BAV-PELLA-TAVR”.

Case 1: A 92-year-old Japanese female presented with CS due to low-flow, low-gradient severe AS and multivessel coronary artery disease. After emergent BAV and Impella 2.5 support, the patient's hemodynamics stabilized. Percutaneous coronary intervention was performed on the right coronary and left anterior descending arteries with Impella 2.5 support. Subsequently, her heart failure (HF) improved and elective TAVR was performed. Case 2: An 89-year-old Japanese female presented with CS due to severe AS. Despite administration of high-dose catecholamines, the patient developed exacerbation of CS due to reduced cardiac output, corresponding to Stage D according to the Society for Cardiovascular Angiography and Interventions (SCAI) classification. Consequently, BAV was performed, which reduced the aortic valve pressure gradient (PG). However, due to persistent hemodynamic instability, Impella 2.5 support was initiated. This procedure resulted in hemodynamic improvement and elective TAVR was performed. Case 3: An 86-year-old Japanese female developed CS with pulmonary edema due to severe AS. Emergent BAV was performed. However, there was no improvement in the PG and hemodynamics, and the initial mild aortic regurgitation worsened to a moderate degree. Therefore, an Impella CP was implanted, which resulted in improved hemodynamics. Following the removal of the Impella CP device, and sub-emergent TAVR was successfully performed.

In all cases, emergent BAV and subsequent hemodynamic support from the Impella were provided as the initial treatment for CS at Stage C/D according to the SCAI classification. This approach improved CS, enabling interventions for concomitant ischemic heart disease, multidisciplinary heart team evaluation, and TAVR with reduced perioperative risk.