Successful destination therapy after stepwise mechanical circulatory support in a patient with cardiogenic shock following mechanical aortic valve replacement

Patients with mechanical aortic valve replacement and end-stage heart failure present major challenges when mechanical circulatory support is required, as transvalvular devices such as the Impella 5.5 are contraindicated. We report a 57-year-old man with idiopathic dilated cardiomyopathy who developed cardiogenic shock after prior mechanical aortic valve replacement. Despite cardiac resynchronization therapy defibrillator support and intra-aortic balloon pumping, he became dialysis dependent. The patient's condition progressively deteriorated, necessitating more robust mechanical circulatory support. Although durable left ventricular assist device implantation was considered, transvalvular Impella 5.5 support was precluded by the mechanical aortic valve, and simultaneous durable left ventricular assist device implantation with redo aortic valve replacement was considered high risk because of poor surgical tolerance and end-organ dysfunction. Therefore, we planned a staged surgical strategy. Reoperative aortic valve replacement with a bioprosthetic valve was therefore performed to enable Impella 5.5 implantation. Impella support resulted in hemodynamic stabilization, end-organ recovery, and improvement in risk stratification. Subsequently, a HeartMate 3 was successfully implanted as destination therapy. The patient recovered progressively and was discharged. This case demonstrates that intentional conversion to a bioprosthetic valve may be a viable strategy to enable advanced mechanical circulatory support.