Successful treatment of

Introduction: Low-flow, low-gradient aortic stenosis (LFLG AS) is a subset of aortic stenosis associated with a poor prognosis and high operative risk, particularly in the presence of concomitant coronary artery disease (CAD) requiring intervention. In patients considered inoperable, minimally invasive approaches often remain the only alternative. However, there are limited data on treatment strategies and outcomes in patients with LFLG AS and severe ischaemic cardiomyopathy undergoing percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR), especially in cases with challenging transfemoral access. Case summary: An 87-year-old male presented with progressive dyspnoea and angina. Diagnostics revealed a non-ST-segment elevation myocardial infarction, acute heart failure, acute-on-chronic renal failure, LFLG AS (aortic valve area of 0.7 cm²), and a left ventricular ejection fraction of 10%. Coronary angiography showed severe CAD requiring revascularization. Due to excessive surgical risk, we planned a staged interventional treatment by Heart Team consensus. First, high-risk PCI with mechanical circulatory support was performed, followed by transfemoral TAVR using a self-expandable 29-mm bioprosthesis via a femoral Y-graft conduit. The patient reported immediate relief of symptoms. Follow-up echocardiography at discharge and at 3 months showed improvement of the aortic valve function and an increase of the ejection fraction to 35%. The patient remained asymptomatic and resumed his daily activities. Discussion: This case demonstrates that Impella®-supported PCI prior to transfemoral TAVR is feasible and safe, even in the presence of a femoral Y-graft, in a patient with LFLG AS and severely reduced ejection fraction.