High Risk PCI and Aortic Valvuloplasty With VA ECMO Support: A Case of Pre-TAVI Hybrid Therapy

Abstract

INTRODUCTION: In patients requiring high risk PCI, the Impella transvalvular LVAD has emerged as a viable option for mechanical circulatory support, but my be difficult in patients with advanced arch vessel disease and or severe aortic valve stenosis1. We present a case that illustrates the benefits of VA ECMO support in a patient with severe arch vessel disease, limited femoral access, and severe aortic stenosis, during combined high risk PCI and balloon aortic valvuloplasty (BAV). CASE PRESENTATION: The patient is an 82 y/o male with advanced lung and peripheral vascular disease who presented with non-ST elevation MI and CHF FC-III. Echo and cardiac cath demonstrated 90% LM stenosis and complete RCA occlusion, as well as severe AS (AVA 0.9 cm2) and EF 20-25%. The patient was referred for high risk TAVI with a calculated STS score of 8.9%. CT angio identified a right subclavian obstruction with limited femoral access (< 7 mm). During preoperative work-up, the patient developed a refractory ventricular arrhythmia, pulmonary edema, and sustained cardiac arrest. Peripheral IABP support was not an option due to the patient's limited peripheral vascular access. The patient was emergently taken to the hybrid OR where VA ECMO support was initiated using femoral and subclavian vein cutdowns. Endarterectomy of the artery was performed to place a 10mm Hemashield Dacron graft. After successful initiation of mechanical support, left brachial access was obtained to stent the LM coronary artery with a drug eluding stent. 5 days after initiation of VA ECMO, the patient had improved significantly and a balloon aortic valvuloplasty was considered to optimize the patient before a TAVI procedure would be attempted. Aortic valvuloplasty was successfully performed via axillary access and VA ECMO support was explanted two days postoperatively. The patient was discharged to a rehab facility with re-evaluation at 2 months for a TAVI procedure. DISCUSSION: Percutaneous transvalvular LVADs, such as the Impella, can provide circulatory support during high risk PCI, but may not be the support of choice when the patient has severe arch vessel disease, limited femoral access, or severe aortic stenosis. Direct axillary/subclavian cutdown with a Hemashield graft can be useful for mechanical support and access during PCI stenting and balloon aortic valvuloplasty. CONCLUSIONS: When mechanical support is warranted in a patient with advanced arch vessel disease, limited femoral access, or severe aortic stenosis, the use of VA-ECMO should be considered. When mechanical support is warranted and access for PCI stenting and/or balloon aortic valvuloplasty is needed, direct axillary/subclavian cutdown with a Hemashield graft should be considered.