(779) Persistent Cardiogenic Shock after Valve in Valve TAVR Rescued with Durable LVAD

IntroductionTrans-catheter Aortic Valve Replacement (TAVR) has revolutionized the treatment of severe AS. However, in the case of a valve-in-valve (ViV) TAVR, the annulus size of the previous valve is a limiting factor and may result in patient prosthesis mismatch (PPM).Case Report68 yo male with history of bicuspid aortic valve and HFrEF (EF 30%) s/p SAVR with #21mm Trifecta valve and bypass to RCA. He was lost to follow up and presented 5 years later in ADHF, EF <10% with severe prosthetic valve stenosis (MG 45mmHg, PG 62mmHg, AT 108cm/s, EOAi 0.2cm2/m2) (Fig A). RCA graft was occluded but not felt to be contributing. He quickly deteriorated to inotrope dependent cardiogenic shock (CS) with a cardiac index of 1.0 l/min/m2 on high doses of inotropes/pressors (Fig B). His case was further complicated by shock liver and renal failure. Decision was made for emergent ViV TAVR with 20mm Edwards Sapien 3 valve with immediate yet not sustained hemodynamic improvement. Prosthetic valve gradient remained elevated (mean 25, PG 45mmHg, DI 0.2) with severe bi-ventricular failure and worsening LV dilation attributed to PPM in the setting of CS. Balloon fracture of the Trifecta valve was not attempted given clinical instability. He developed multi-organ failure requiring temporary MCS. He was briefly stabilized on IABP before transitioning to axillary Impella 5.5 while undergoing durable LVAD work up. Over the next week, his end-organ function recovered, and he gained strength with physical therapy. Two weeks later he underwent HeartMate 3 LVAD with planned temporary RVAD, which was decannulated after 5 days and he was discharged 3 weeks later. Final echo revealed successful unloading (LVIDd 4.4cm) with slightly improved LV systolic function (EF 20%) (Fig C).SummaryPrior SAVR complicates the use of TAVR, especially in those presenting in extremis. PPM is a known complication of ViV TAVR, especially with Trifecta valves which are resistant to non-compliant balloon dilation and fracture. LVAD therapy can be successfully used to rescue such patients. Trans-catheter Aortic Valve Replacement (TAVR) has revolutionized the treatment of severe AS. However, in the case of a valve-in-valve (ViV) TAVR, the annulus size of the previous valve is a limiting factor and may result in patient prosthesis mismatch (PPM). 68 yo male with history of bicuspid aortic valve and HFrEF (EF 30%) s/p SAVR with #21mm Trifecta valve and bypass to RCA. He was lost to follow up and presented 5 years later in ADHF, EF <10% with severe prosthetic valve stenosis (MG 45mmHg, PG 62mmHg, AT 108cm/s, EOAi 0.2cm2/m2) (Fig A). RCA graft was occluded but not felt to be contributing. He quickly deteriorated to inotrope dependent cardiogenic shock (CS) with a cardiac index of 1.0 l/min/m2 on high doses of inotropes/pressors (Fig B). His case was further complicated by shock liver and renal failure. Decision was made for emergent ViV TAVR with 20mm Edwards Sapien 3 valve with immediate yet not sustained hemodynamic improvement. Prosthetic valve gradient remained elevated (mean 25, PG 45mmHg, DI 0.2) with severe bi-ventricular failure and worsening LV dilation attributed to PPM in the setting of CS. Balloon fracture of the Trifecta valve was not attempted given clinical instability. He developed multi-organ failure requiring temporary MCS. He was briefly stabilized on IABP before transitioning to axillary Impella 5.5 while undergoing durable LVAD work up. Over the next week, his end-organ function recovered, and he gained strength with physical therapy. Two weeks later he underwent HeartMate 3 LVAD with planned temporary RVAD, which was decannulated after 5 days and he was discharged 3 weeks later. Final echo revealed successful unloading (LVIDd 4.4cm) with slightly improved LV systolic function (EF 20%) (Fig C). Prior SAVR complicates the use of TAVR, especially in those presenting in extremis. PPM is a known complication of ViV TAVR, especially with Trifecta valves which are resistant to non-compliant balloon dilation and fracture. LVAD therapy can be successfully used to rescue such patients.