Case report: management of refractory cardiogenic shock with Impella 5.5 in patients with transcatheter aortic valves

Background Impella is a transaortic valvular pump commonly utilized in patients with cardiogenic shock. However, its use with transcatheter aortic valves (TAVI) remains rare. We present two cases where surgical Impella 5.5 was placed across both Sapien 3 Ultra and Evolute Pro+ valves. Case summary Patient 1: A 74-year-old male with history of ischaemic cardiomyopathy with ejection fraction 20-25% status post-cardiac resynchronization therapy with a defibrillator, severe aortic stenosis (AS) status post-recent Sapien 3 Ultra TAVI presented with cardiogenic shock. Due to persistent unstable haemodynamic status, Impella 5.5 was placed and was utilized as a bridge to left ventricular assist device. Patient 2: A 74-year-old male with a history of alcoholic cirrhosis and AS underwent Evolute Pro+ TAVI at outside facility. The implantation was complicated by left main coronary artery occlusion, leading to cardiogenic shock. Patient required femoral veno-arterial extracorporeal membrane oxygenation (ECMO) support and emergent single vessel coronary bypass of a saphenous venous graft to the left anterior descending artery. Extracorporeal membrane oxygenation was decannulated on Day 20 and Impella 5.5 was placed as a bridge to recovery. In both cases, there were no procedural complications or residual aortic or perivalvular regurgitation. Discussion Impella 5.5 implanted via the axillary surgical cutdown is safe and feasible approach to manage refractory cardiogenic shock in patients with TAVI including different types of valves, Sapien 3 Ultra, and Evolute Pro+. As it can provide full haemodynamic support, Impella 5.5 can be used as bridge to recovery or durable mechanical support.