Transcatheter aortic valve implantation (TAVI) is acknowledge method of treatment for patients with severe aortic stenosis whose surgical risk is too high. Nevertheless, in some cases unconventional methods have to be applied prior to definitive decisions considering treatment. (1)

70 year-old-male without any medical history, was admitted because of cardiogenic shock and pulmonary edema. Parenteral diuretics and high dose inotropic therapy with dobutamine and dopamine were administered, along with antibiotics for pneumonia. Echocardiographic examination described biventricular cardiomyopathy (EF 15%), severe low flow-low gradient aortic stenosis (max PG 35mmHg, AVA 0.6cm²), intraventicular (iv) dyssynchrony due to left bundle branch block (LBBB) (QRS 178ms) and sever pulmonary hypertension. Treatment was complicated with frequent ventricular tachycardia, which required continuous treatment with amiodarone and magnesium. On given medication partial volume unloading was achieved, despite which patient remained hemodynamically unstable, dependent on inotropic support, NYHA 4 functional status. As palliative method, aortic valve balloon valvuloplasty (BAV) was preformed, followed with increase in AVA (1.0cm²) and decline of gradient (maxPG15mmHg), with rise in systemic pressure. After procedure inotropic therapy was discontinued, but with persistent ventricular ectopic activity (nsVT). In spite of partial volume and pressure unloading, echocardiographic signs of iv dyssynchrony are still evident, with consequently marked reduction in systolic function, because of which permanent CRT-D device was implanted. Considering residual mechanical dyssynchrony, echocardiographic optimization was preformed (after pre-excitation of left electrode - EF 25%) and patient was discharged. After discharge appropriate defibrillations were observed in ER. In 6 weeks follow-up patient had no symptoms (NYHA 2). Positive remodeling of myocardium has been observed (EF 35%, AVA 0.8cm²). TAVI, as final treatment method was recommended to patient, but he refused it.

In conclusion, hemodynamically and rhythmological unstable patient with terminal valvular cardiomyopathy and mechanical dyssynchrony due to LBBB, was stabilized using BAV and cardiac resynchronization therapy. Using unconventional treatment methods, we provided rehabilitation period and predispositions for surgical or percutaneous treatment of aortic stenosis.