Recommended Citation
Toll A, Diaz Sierra A, Gonzalez Martinez P, et al. Valvuloplasty Meets Impella: A Rescue Approach for Cardiogenic Shock in the Setting of Critical Aortic Stenosis. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Introduction/Background:
The combination of severe aortic stenosis and cardiogenic shock carries high morbidity and mortality. In patients who are not immediate candidates for emergent transthoracic aortic valve replacement (TAVR) or transfer to a tertiary center, balloon aortic valvuloplasty (BAV) may serve as a temporizing strategy to stabilize hemodynamics and improve end-organ perfusion.
Description:
A 78-year-old man with a past medical history of essential hypertension, hyperlipidemia, nonischemic cardiomyopathy and heart failure with reduced ejection fraction presented with acute decompensated heart failure. Transthoracic echocardiography demonstrated critical AS with an aortic valve area (AVA) of 0.26 cm2, peak velocity 6.2 m/s, mean gradient 77 mmHg, and stroke volume index 20.9 mL/m2, consistent with severe fixed outflow obstruction. Despite escalating intravenous diuretics and guideline-directed medical therapy, his condition deteriorated, progressing to cardiogenic shock with evidence of systemic hypoperfusion. Laboratory evaluation revealed lactic acidosis (7.5 mmol/L) and NT-proBNP >70,000 pg/mL. Given ongoing shock and lack of immediate TAVR availability, emergent BAV was performed using an 18-mm Z-Med II balloon. Invasive hemodynamics confirmed a pre-intervention LV-to-aortic gradient of 63 mmHg. Following balloon inflation, the patient developed pulseless electrical activity arrest secondary to transient severe aortic insufficiency. Return of spontaneous circulation was achieved, and an Impella CP device was placed for mechanical circulatory support. Over the next three days, hemodynamics improved, allowing successful device weaning and removal. Repeat echocardiography demonstrated improved AVA to 0.6 cm2 with mild-to-moderate aortic insufficiency. After clinical stabilization, the patient underwent successful TAVR one month later without complications.
Discussion:
BAV can serve as a bridge to definitive therapy in patients with both cardiogenic shock and severe aortic stenosis when an emergent TAVR or prompt transfer is not feasible. Although not a substitute for TAVR or surgical valve replacement, BAV can acutely reduce left ventricular outflow tract obstruction, improve cardiac output, and restore end-organ perfusion. This case highlights both the potential life-saving role of BAV and the importance of mechanical circulatory support in managing periprocedural instability.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
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Valvuloplasty Meets Impella: A Rescue Approach for Cardiogenic Shock in the Setting of Critical Aortic Stenosis
Introduction/Background:
The combination of severe aortic stenosis and cardiogenic shock carries high morbidity and mortality. In patients who are not immediate candidates for emergent transthoracic aortic valve replacement (TAVR) or transfer to a tertiary center, balloon aortic valvuloplasty (BAV) may serve as a temporizing strategy to stabilize hemodynamics and improve end-organ perfusion.
Description:
A 78-year-old man with a past medical history of essential hypertension, hyperlipidemia, nonischemic cardiomyopathy and heart failure with reduced ejection fraction presented with acute decompensated heart failure. Transthoracic echocardiography demonstrated critical AS with an aortic valve area (AVA) of 0.26 cm2, peak velocity 6.2 m/s, mean gradient 77 mmHg, and stroke volume index 20.9 mL/m2, consistent with severe fixed outflow obstruction. Despite escalating intravenous diuretics and guideline-directed medical therapy, his condition deteriorated, progressing to cardiogenic shock with evidence of systemic hypoperfusion. Laboratory evaluation revealed lactic acidosis (7.5 mmol/L) and NT-proBNP >70,000 pg/mL. Given ongoing shock and lack of immediate TAVR availability, emergent BAV was performed using an 18-mm Z-Med II balloon. Invasive hemodynamics confirmed a pre-intervention LV-to-aortic gradient of 63 mmHg. Following balloon inflation, the patient developed pulseless electrical activity arrest secondary to transient severe aortic insufficiency. Return of spontaneous circulation was achieved, and an Impella CP device was placed for mechanical circulatory support. Over the next three days, hemodynamics improved, allowing successful device weaning and removal. Repeat echocardiography demonstrated improved AVA to 0.6 cm2 with mild-to-moderate aortic insufficiency. After clinical stabilization, the patient underwent successful TAVR one month later without complications.
Discussion:
BAV can serve as a bridge to definitive therapy in patients with both cardiogenic shock and severe aortic stenosis when an emergent TAVR or prompt transfer is not feasible. Although not a substitute for TAVR or surgical valve replacement, BAV can acutely reduce left ventricular outflow tract obstruction, improve cardiac output, and restore end-organ perfusion. This case highlights both the potential life-saving role of BAV and the importance of mechanical circulatory support in managing periprocedural instability.
Affiliations
Advocate Masonic Medical Center