Extracorporeal Membrane Oxygenation for Transcarotid Transcatheter Aortic Valve Replacement in Severe Aortic Stenosis

Patients with severe aortic stenosis and profoundly reduced left ventricular ejection fraction (LVEF) face a prohibitive risk of intraprocedural hemodynamic collapse during transcatheter aortic valve replacement (TAVR). This risk is exacerbated when complex valve anatomy prolongs the procedure, and it is compounded further when hostile iliofemoral anatomy precludes conventional transfemoral access.

We present a 71-year-old woman with severe aortic stenosis, a rigid type 0 bicuspid aortic valve, and an LVEF of 15%. Preprocedural imaging revealed narrow iliofemoral arteries prohibitive for a standard TAVR delivery system. Guided by a multidisciplinary heart team approach focusing on the "access-valve-coronary-brain" axis, a tailored strategy was executed. Prophylactic venoarterial extracorporeal membrane oxygenation (ECMO) was established via the femoral vessels to provide continuous circulatory support, followed by successful TAVR via the left common carotid artery. The procedure was well tolerated, and the patient demonstrated rapid reverse ventricular remodeling, with LVEF improving to 48% at discharge.

Integrating prophylactic ECMO with transcarotid access is a feasible procedural strategy to mitigate the risk of intraprocedural collapse in patients with severe left ventricular dysfunction, complex bicuspid aortic valve anatomy, and prohibitive femoral access.