Transcatheter Management of Severe Aortic Stenosis, Acute Pulmonary Embolism, and Gastrointestinal Bleeding.

backgroundThe concurrent presentation of severe aortic stenosis (AS), acute pulmonary embolism (PE), and gastrointestinal bleeding creates a clinical dilemma where treating one condition may exacerbate another. CASE SUMMARY: A 72-year-old woman presented with fatigue, palpitations, and melena. She was found to have severe AS, bilateral acute PE, and a bleeding duodenal ulcer. After initial stabilization with transfusion, we used a staged multidisciplinary approach: catheter-directed thrombectomy with adjunctive balloon angioplasty for residual stenosis, followed by transfemoral transcatheter aortic valve replacement. DISCUSSION: This case illustrates the challenges of coexisting AS, gastrointestinal bleeding, and PE. Although Heyde syndrome was considered a possible unifying mechanism, absent angiodysplasia and von Willebrand factor testing preclude definitive diagnosis. A staged, physiology-driven strategy prioritized immediate threats and enabled safe definitive therapy. TAKE-HOME MESSAGES: In patients with competing thrombotic and bleeding pathologies, a staged, physiology-first approach prioritizing the most immediate threat enables safe sequential intervention. Percutaneous techniques minimize cumulative risk in high-risk patients.