Emergency PCI and TAVR Supported by Extra VAD Without CT Assessment

An emergency percutaneous coronary intervention (PCI) combined with transcatheter aortic valve replacement (TAVR) was performed at Harbin Medical University Second Affiliated Hospital under extracorporeal ventricular assist device (Extra VAD) support. The procedure was conducted without preoperative CT assessment due to the patient's clinical condition.

Patient Profile

Key Findings

• Serum troponin I: 0.074 ng/mL

• Pro-BNP: 10,100 ng/L

• Severe left ventricular dilation

• Left ventricular ejection fraction (LVEF): 17%

• Severe aortic valve stenosis with low-flow, low-gradient characteristics

• Moderate mitral regurgitation

• Mild tricuspid regurgitation

Diagnoses

• NSTEMI

• Severe aortic valve stenosis

• Killip class III heart failure

• Severe left ventricular systolic dysfunction

• Paroxysmal atrial fibrillation

• Renal insufficiency

• Anemia

Procedure Strategy

• Assessment determined the patient was unable to tolerate conventional open-heart surgery under general anesthesia

• Decision to perform PCI and TAVR under sedation 

• Use of temporary extracorporeal ventricular assist device (Extra VAD) for circulatory support

• Venous drainage via femoral vein–interatrial septum–left upper pulmonary vein–left atrium

• Arterial perfusion via femoral artery

• Coronary intervention under Extra VAD support:

    *  Rotational atherectomy of severely calcified circumflex artery lesion

    *  Drug-eluting stent implantation in the LAD, circumflex artery, and LM

• TAVR performed without CT guidance due to intolerance:

    *  Valve sizing and deployment guided by echocardiography and DSA

    * Balloon predilation followed by implantation of a transcatheter valve

    *   Post-dilation performed to optimize valve expansion

Extra-VAD

Transseptal puncture	Guidewire advanced into the left upper pulmonary vein

Venous drainage cannula positioned in the left upper pulmonary vein	PCI performed under Extra-VAD support

PCI

coronary angiography showing severe stenosis of the circumflex artery

Rotational atherectomy of the calcified circumflex lesion	Balloon dilation of the stenotic segment

Proximal circumflex artery dilation	Stent implantation

Post-dilation of the stent	Final angiography demonstrating restoration of coronary blood flow

TAVR

Aortic root angiography showing severely restricted leaflet motion	Aortic root measurements based on angiographic assessment

Predilation with an 18-mm balloon	Selection of TF23 transcatheter valve, deployed at the 0-position

Stable valve release to full expansion	Angiographic assessment showing acceptable valve position with visible compression

Left anterior oblique view confirming valve position around the 0-position	Valve detachment without movement

Post-dilation with a 20-mm balloon	Final angiography showing acceptable valve position with minimal paravalvular leakage

Aortic arch angiography showing no vascular injury	Peripheral vascular assessment showing no injury

Postoperative Course

• Immediate relief of coronary and aortic valve obstruction

• Postoperative echocardiography showed:

  *  LVEF improved to 39%

  *  Normal opening and closing of the transcatheter aortic valve

  *  Mean transvalvular gradient reduced to 4.8 mmHg

  *  Mild paravalvular leakage

• Patient demonstrated stable recovery following the procedure

• Clinical Insights

• Emergency TAVR combined with PCI can be a feasible option for patients with severe aortic stenosis and acute decompensated cardiac conditions

• Extra VAD provided essential short-term circulatory support in the setting of extremely low LVEF and high risk of hemodynamic collapse

• Performing TAVR without CT assessment significantly increases procedural complexity and relies on advanced imaging interpretation and operator experience

• Further clinical experience is required to evaluate outcomes of Extra VAD–supported emergency PCI and TAVR in similar high-risk populations