• Francesco Burzotta, Roberto Nerla, and Carlo Trani.
• Institute of Cardiology, Catholic University of the Sacred Heart, Largo A. Gemelli 8, 00168 Roma, Italy. f.burzotta@rm.unicatt.it.
• J Invasive Cardiol. 2016 Jan 1; 28 (1): E1-5.

BackgroundThe optimal management of cardiogenic shock (CS) occurring in the presence of acute coronary syndromes, severe aortic stenosis, and poor left ventricular function has not been established. Recently, the availability of new assistance devices and techniques has provided novel management opportunities. In particular, when compared with surgical approaches, percutaneous procedures have the advantage of allowing "staged" interventions, in which different steps are planned according to the patient's evolving clinical conditions.Case PresentationA woman was admitted with an acute coronary syndrome complicated by CS on a background of severe aortic stenosis, severe left ventricular dysfunction, and severe calcific peripheral artery disease. We successfully treated her with emergency percutaneous coronary intervention (PCI) to left main stem followed by balloon aortic valvuloplasty (BAV). After BAV, acute aortic regurgitation developed with sudden hemodynamic collapse. In such a catastrophic setting, we successfully achieved immediate stabilization by implantation of an Impella CP device (Abiomed). After 1 day of Impella CP assistance, we successfully performed elective transfemoral aortic revalving through the same femoral access by facilitating device crossing and hemostasis with transradial balloon peripheral angioplasty and by practicing a novel technique we called "pump rewiring."ConclusionThis case example demonstrates how a tailored step-by-step strategy including PCI, BAV, peripheral angioplasty, percutaneous ventricular assistance, and transcatheter aortic valve implantation (TAVI) allowed the successful treatment of a critical patient with CS. Impella CP could be considered an effective bridge to TAVI in patients developing aortic regurgitation after BAV, since maintaining arterial access can be achieved using the pump-rewiring technique.

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