VA-ECMO Weaning in Low-Flow Low-Gradient Aortic Stenosis Post STEMI and ECPR.

BACKGROUND: Low-flow, low-gradient (LF-LG) severe aortic stenosis (AS) in post-ST-elevation myocardial infarction cardiogenic shock supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) presents complex diagnostic and therapeutic challenges. Retrograde extracorporeal membrane oxygenation flow alters cardiac loading conditions and transvalvular flow, complicating accurate assessment of valvular disease. CASE SUMMARY: A 52-year-old woman with inferolateral ST-elevation myocardial infarction complicated by ventricular fibrillation cardiac arrest, was placed on VA-ECMO support. Extracorporeal membrane oxygenation weaning attempts failed due to severe bicuspid LF-LG AS. After multidisciplinary evaluation, she underwent transcatheter aortic valve implantation and was subsequently successfully weaned from VA-ECMO. DISCUSSION: Mechanical circulatory support alters preload, afterload, and transvalvular flow, making differentiation between true severe AS and low-flow states from cardiogenic shock or ventricular dysfunction difficult. No societal guidelines exist for grading LF-LG AS severity or guiding VA-ECMO weaning in this setting. TAKE-HOME MESSAGES: VA-ECMO complicates LF-LG AS assessment. Multimodal, multidisciplinary evaluation enables accurate diagnosis and appropriate intervention.