Emergency Transcatheter Aortic Valve Implantation in Mixed Bicuspid Aortic Valve Disease With a Horizontal Aorta: Return of Spontaneous Circulation Only After Left Ventricular Unloading

A 74-year-old man with mixed bicuspid aortic valve disease, combining severe calcific stenosis with severe regurgitation, and a left ventricular ejection fraction of 26% presented in normotensive cardiogenic shock with anuria and an arterial lactate of 12 mmol/L. Computed tomography showed a fibrocalcific left-right raphe and an aortic angulation of 66 degrees. Emergency transfemoral transcatheter aortic valve implantation was undertaken. The delivery system could not be advanced across the aortic arch despite escalation of guidewire support, and ventricular fibrillation degenerated into pulseless electrical activity refractory to resuscitation. Peripheral venoarterial extracorporeal membrane oxygenation was established, after which a 29 mm self-expanding prosthesis was implanted with an acceptable haemodynamic result and patent coronary ostia. Pulseless electrical activity nonetheless persisted. Return of spontaneous circulation followed only after a microaxial pump was advanced retrogradely across the freshly deployed prosthesis under fluoroscopic guidance alone, establishing an ECMELLA configuration. The patient died of multiorgan failure two days later. This sequence identifies continued left ventricular loading, rather than any residual valve lesion, as the reason resuscitation failed, and argues for anticipating unloading when extracorporeal support is instituted across a valve just rendered competent in a severely dysfunctional ventricle. The outcome appeared determined by end-organ injury already established before intervention.