Aortic Valve Replacement Supported with Microaxial Flow Pump Implantation in Patients Presenting with Severely Impaired Left Ventricular Function: Technical Aspects and Early Outcomes

All articles of this category (opens in new window) Background: Microaxial flow pump (Impella) is an established form of endovascular mechanical circulatory support, initially introduced for patients with cardiogenic shock and later extended to those with severely reduced left ventricular ejection fraction (LVEF) undergoing high-risk interventions. Its application following surgical aortic valve replacement (SAVR) remains rare, with only limited data reported. We present our single-center experience with intraoperative Impella 5.5 implantation across the aortic prosthesis under direct vision and echocardiographic guidance before weaning from cardiopulmonary bypass (CPB). Methods: Between February 2022 and August 2025, 16 patients (three females) with NYHA classes III to IV heart failure, severe aortic valve disease, and markedly reduced LVEF (mean 23 ± 5%) underwent SAVR with concomitant Impella 5.5 support. Mean age was 66.5 ± 8.7 years, and the mean logistic EuroSCORE was 18.2 ± 13.4%. All patients were deemed unsuitable for interventional procedures by the interdisciplinary heart team and scheduled for protected SAVR. Concomitant procedures included mitral valve surgery ( n = 7), coronary artery bypass grafting ( n = 6), and aortic surgery ( n = 3). Before removal of the cross-clamp, a guidewire was advanced across the prosthesis into the left ventricle under direct vision via a vascular graft anastomosed to either the ascending aorta ( n = 12) or the axillary artery ( n = 4). Finally, Impella positioning was guided echocardiographically prior to weaning from CPB. Results: Mean cross-clamp and CPB times were 112 ± 44 and 168 ± 51 minutes, respectively. Five patients required surgical revision for bleeding, none related to the Impella procedure (graft, wiring, implantation). All patients were successfully weaned from support, with a duration ranging from 3 to 31 days. Prosthetic valve function remained preserved in all cases. Mean ICU and hospital stay was 14.7 ± 13.9 and 24.4 ± 13.5 days. Thirty-day mortality occurred in one patient due to a disabling stroke associated with heparin-induced thrombocytopenia. No further device-related complications were observed. At the last follow-up, 15 patients (94%) demonstrated good clinical recovery. Conclusion: Intraoperative Impella 5.5 implantation under direct vision and echocardiographic guidance following SAVR is a feasible, safe, and reproducible strategy. This approach preserves prosthetic valve integrity, enables precise positioning, and provides effective bridge-to-recovery or bridge-to-decision support in high-risk patients with severely impaired LVEF who are unsuitable for alternative interventions. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany