Direct Aortic Transcatheter Aortic Valve Implantation under Subclavian Venoarterial Extracorporeal Membrane Oxygenation and Aortography by Pigtail Catheter through the Return Cannula for Severe Aortic Valve Stenosis: A Case Report

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Objective: Venoarterial extracorporeal membrane oxygenation (V-A ECMO) provides effective cardiac and respiratory support in patients with unstable hemodynamics undergoing transcatheter aortic valve implantation (TAVI). In these cases, factors such as atheromatous plaque, small vessel diameter, and a shaggy aorta could complicate the choice of access route.

Case Presentation: A 77-year-old female with severe aortic stenosis was diagnosed with acute decompensated heart failure and presented with paroxysmal atrial fibrillation and a rapid ventricular response. Transthoracic echocardiography revealed diffuse severe hypokinesis of the left ventricle, and medical treatment yielded a poor response. Her Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation 2 scores were 17.2% and 31.1%, respectively. The heart team selected TAVI with V-A ECMO as the preferred approach. Computed tomography revealed a shaggy aorta extending from the aortic arch to the descending aorta, a significant atheromatous plaque at the origin of the left subclavian artery, and significant narrowing of both external iliac arteries. Therefore, a direct aortic TAVI (DA-TAVI) was performed with right subclavian V-A ECMO. During the procedure, a non-kinking sheath was inserted into the V-A ECMO return cannula, and a pigtail catheter was advanced through it for precise aortography. The procedure was successful, and the postoperative clinical course was favorable. She was transferred to a referral hospital on day 36 for cardiac rehabilitation.

Conclusion: We report a successful DA-TAVI using subclavian V-A ECMO and pigtail catheter positioning above the aortic valve through the V-A-ECMO return cannula.