Pathologic findings of aortic valve leaflet injury via IMPELLA insertion

A 27-year-old male was admitted to our hospital due to lymphocytic fulminant myocarditis. He required ECPELLA (V-A ECMO+Impella) management for 10 days. His cardiac function did not improve, and needed an external ventricular-assisted device (VAD) for 5 months. The severity of aortic insufficiency was moderate (Figure 1A), and he underwent aortic valve replacement during an implantable VAD (HeartMate 3TM) implantation. The aortic valve leaflets obtained at the surgery were pathologically evaluated. All leaflets showed thickening (Figure 1B). Haematoxylin and eosin staining revealed penetration of erythrocytes into the stroma in all leaflets (Figure 1C). Macrophages surrounded the deformed erythrocytes (Figure 1E). In addition, von Kossa staining showed scattered microcalcifications (Figure 1D and F). In experiments on mice, guidewire injury to the aortic valve causes infiltration of macrophages into the damaged valve leaflets and are associated with calcification.1,2 In the context of the present case, it is suggested that the aortic valve was injured by IMPELLA insertion, red blood cells attached and invaded, and calcification might be induced by macrophages that phagocytosed them. All authors declare no conflict of interest for this contribution. The data underlying this article will be shared on reasonable request to the corresponding author.