Pathology of Sapien 3 After Impella-CP Insertion for Acute Coronary Syndrome With Cardiogenic Shock

An 89 year-old man, who had undergone transcatheter aortic valve (TAV) implantation with Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) 7 months ago, died due to sepsis 7 days after percutaneous coronary intervention (PCI) for cardiogenic shock with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella-CP (Abiomed, Inc., Danvers, MA, USA) support (Figure A,B; Supplementary Movies 1,2).

Figure.

Pathological assessment of the transcatheter aortic valve after Impella implantation. Blue arrow shows culprit lesion (A,B). Low (C–E) and high (F–H) power images show foreign body (C,G,H), identified by polarized light microscopy (F). Mild fibrin thrombus around the foreign body with minimal inflammation (H). No fibrin thrombus is seen the other leaflets (D,E). DES, drug-eluting stent; ECMO, extracorporeal membrane oxygenation; LCC, left coronary cusp; NCC, noncoronary cusp; RCC, right coronary cusp.

Pathology of the explanted TAV leaflets (Figure C–H) revealed a foreign body (FB) attachment on the ventricular side of the left coronary cusp, identified by polarized light microscopy (Figure C,F–H). Although there was some fibrin thrombus around the FB with minimal inflammatory cell reaction, there was no fibrin thrombus on the ventricular side of the other leaflets (Figure D,E), suggesting that the fibrin thrombus was a FB reaction. There were no other structural changes on the TAV leaflets. As the fibrin thrombus was in a relatively early phase, the FB had attached with Impella insertion before explantation, not on the day of TAV implantation 7 months before.

Because the FB reaction was a possible response to minor injury such as endothelial denudation,¹ within 7 days use of Impella support via a TAV might only be feasible with normal functioning bioprosthetic aortic valves.

Disclosures

Y.I. is a member of Circulation Journal’s Editorial Team. No financial support was provided for this manuscript.

Supplementary Files

Supplementary Movie 1. Guiding catheter engagement.

Supplementary Movie 2. Final angiography.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-22-0818

Reference

• 1.   Higashi H, Nishimura T, Aono J, Sakaue T, Kurata M, Izutani H, et al. Pathological evidence of native aortic valve injury after Impella support. Circ Heart Fail 2021; 14: e007571.