When the “wrong” device is the right choice: Impella CP–assisted left main PCI as a bridge to TAVI in critical aortic stenosis

Background Severe aortic stenosis (AS) with concomitant multivessel coronary artery disease (CAD) is a high-risk clinical scenario. The Impella CP carries an absolute manufacturer contraindication in critical AS (aortic valve area [AVA] ≤0.60 cm 2 ) and is generally avoided in severe AS given risks of valve injury, acute aortic regurgitation, and device malposition. However, accumulating case-level and registry evidence supports feasibility in selected patients when alternatives are limited. Case summary An 87-year-old woman with critical AS (AVA 0.40 cm 2 , mean gradient 47 mmHg) and severe multivessel CAD, including 80% ostial left main (LM) and 70% proximal right coronary artery (RCA) stenoses, presented with acute decompensated heart failure following recent hip surgery. After Heart Team review, a staged strategy was pursued: intra-aortic balloon pump (IABP) supported RCA percutaneous coronary intervention (PCI), followed by Impella CP–assisted LM PCI without prior balloon aortic valvuloplasty (BAV) when invasive hemodynamic reassessment demonstrated insufficient reserve, and same-admission transcatheter aortic valve implantation (TAVI) with a 25 mm Navitor valve. The Impella crossed the valve in under 1 min with minimal resistance, and LM PCI was completed without hemodynamic compromise. At 3 years she remained alive, event-free, and living independently. Conclusion To our knowledge, this is the smallest AVA reported in which Impella CP was deployed without prior BAV, supporting feasibility of Impella-assisted high-risk LM PCI as a bridge to TAVI in selected patients when individualized Heart Team decision-making and a defined contingency plan are in place.