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

Introduction: 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 presentation: 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. Discussion: 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.