Staged Management with Transcatheter Aortic Valve Replacement in a Patient with ST-Segment Elevation Myocardial Infarction, Low-Gradient Aortic Stenosis, and Recurrent Cardiogenic Shock: A Case Report

Background and Clinical Significance: Cardiogenic shock after successful culprit-vessel revascularization may remain multifactorial when important structural heart disease coexists. Case Presentation: We report an 81-year-old man with extensive anterior ST-segment elevation myocardial infarction, low-gradient calcific aortic stenosis (AS) with reduced left ventricular ejection fraction, and cardiogenic shock. Primary percutaneous coronary intervention of a completely occluded proximal left anterior descending artery was performed under intra-aortic balloon pump (IABP) support. Echocardiography showed an aortic valve area of 0.53 cm2, a mean transvalvular gradient of 25 mmHg, and a left ventricular ejection fraction of 32%. Although the findings raised concern for a classical low-flow, low-gradient AS phenotype, the low-flow state and true-severe AS could not be formally confirmed because stroke-volume index, dobutamine stress echocardiography, and standardized CT calcium scoring were unavailable. After IABP removal on day 6, profound recurrent shock with lactic acidosis and multiorgan hypoperfusion developed on day 10. IABP reinsertion was followed by improvement in systemic perfusion, whereas brief trial-off periods reproduced hemodynamic and symptomatic deterioration. TAVR was performed on day 24 after recovery of end-organ function, discontinuation of vasoactive drugs, partial platelet recovery, and completion of CT-based procedural planning. IABP was removed the next day, and the patient was discharged on day 30 with an ejection fraction of 42%. Conclusions: Recurrent shock after successful culprit-vessel reperfusion should prompt reassessment for persistent structural hemodynamic burdens. Temporary support may serve as a bridge to recovery and individualized procedural planning in selected patients, but the observed improvement after TAVR represents a temporal association in a multifactorial shock state and should not be interpreted as evidence for routine IABP use in infarct-related cardiogenic shock or a predetermined delay before valve intervention.