Impella‐Assisted High‐Risk Percutaneous Coronary Intervention in Cardiogenic Shock With Low‐Flow, Low‐Gradient Aortic Stenosis and Multivessel Coronary Artery Disease: A Case Report

ABSTRACT Patients with cardiogenic shock, low‐flow, low‐gradient aortic stenosis, and multivessel coronary artery disease who are ineligible for surgery present a major therapeutic challenge. Percutaneous mechanical circulatory support may facilitate revascularization in this high‐risk population. A 69‐year‐old man presented after a mechanical fall and was found to have non–ST‐elevation myocardial infarction, acute decompensated heart failure, low‐gradient aortic stenosis, and multivessel coronary artery disease. Echocardiography showed a left ventricular ejection fraction (LVEF) of 25%–30% with mild left ventricular dilation and mildly reduced right ventricular systolic function. Laboratory testing demonstrated elevated troponin, markedly elevated B‐type natriuretic peptide, and acute kidney injury. Chest radiography revealed bilateral pleural effusions and mild atelectasis. Surgical revascularization was not pursued, as the patient was considered at prohibitive operative risk by cardiothoracic surgery. The patient developed cardiogenic shock requiring Impella 5.5 support and subsequently underwent Impella‐assisted high‐risk PCI to the left anterior descending artery. He was successfully weaned from mechanical support, renal function recovered, and guideline‐directed medical therapy was optimized. He was discharged with a wearable cardioverter‐defibrillator and planned repeat echocardiography. This case highlights the role of percutaneous mechanical circulatory support in enabling high‐risk PCI in patients with cardiogenic shock, pseudo‐severe aortic stenosis, and multivessel coronary artery disease when surgical options are not feasible.