Techniques to overcome difficult delivery of the Impella CP device through a previously placed transcatheter aortic valve.

The utilization of mechanical circulatory support (MCS) for complex percutaneous coronary intervention (PCI) in patient with previous bioprosthetic aortic valve replacement continues to increase. This is due to an aging population and increased utilization of transcatheter aortic valve replacement (TAVR) to treat symptomatic severe aortic stenosis (AS). These patients often have concurrent high complexity coronary artery disease (CAD). Various strategies are available for the management of significant CAD in patients undergoing TAVR, including PCI before or after TAVR. However, placement of the Impella (Abiomed Danvers, MA) device in the left ventricle post TAVR can be challenging based on the device interaction with the TAVR cage or angulations of the ascending aorta. We describe a case of unsuccessful delivery of the Impella device through a previously placed 26 mm Sapien 3 TAVR (Edwards Irvine, CA) valve and the techniques that lead to successful placement of the device and review the tips and techniques that operators can employ to optimize success.