P92 ADVANCED CIRCULATORY SUPPORT IN A PATIENT WITH ISCHEMIC HEART DISEASE, SEVERE AORTIC STENOSIS AND CARDIAC TAMPONADE

Abstract

Abstract The use of mechanical left ventricle assistance device in the context of severe aortic stenosis is far from routine. The clinical case we’re presenting highlights the possibility of achieving therapeutic success through appropriate patient selection and choice of the most useful strategy based on the clinical scenario. Our patient is a 70 years old man with several cardiovascular risk factors (DM2, hypertension, active smoker, overweight), CKD IV; his clinical history is characterized by NSTEMI in 2010, treated with PCI and subsequent implantation of 2 DES (on LAD and RM), and by an hospital admission in 2019 for AHF with diagnosis of severe AS. He refused any invasive treatment for underlying valvopathy. In January 2021, a dual–chamber pacemaker implant was required due to the finding of 3rd degree AV block: again, TAVI was refused. A few days after the last discharge, a new ER admission was necessary: the patients had dyspnea (NYHA III–IV) with severe EF depression (50–>25%) and slight troponin elevation: no significant lesions were discovered by coronarography exam. The patient finally agreed to start examinations preparatory to TAVI. After resolution of AHF and approximately 14 days after coronarography, the patient developed pericardial effusion to tamponade, of possible uremic etiology: in addition to compression on the right chambers, echocardiography showed a further dramatic decline in EF (10–15%); despite placement of pericardial drainage and IABP, the initiation of advanced amine support and mechanical ventilation, the patient was classified Intermacs 2. Following a collegial discussion (interventional cardiologist, cardiac surgeon and anesthesiologist), it was decided to perform procedure in the cath–lab in order to undertake an advanced support strategy as birdge–to–therapy: – Valver valvuloplasty with increasing balloon size (18 mm – 20 mm – 23 mm – 25 mm). Rapid pacing was performed through previously implanted PMK, resulting in subsequent hemodynamic benefit (mean gradient 45–>25 mmHg); – Placement of Impella CP (P8, output 3–3.2 L/min). The following post–procedural hospitalization, despite the need for antibiotic therapy and multiple transfusions, was characterized by a progressive hemodynamics improvement until feasibility of weaning from both mechanical and amine therapy and discharge to the rehabilitation center in anticipation of TAVR procedure, which will then be successfully performed in October 2021.