An 80-year-old female patient with a prior history of hypertension, chronic hepatitis C carrier, paroxysmal atrial fibrillation, cerebrovascular accident, and rheumatic heart disease with known severe MR. She was admitted to the cardiac intensive care unit due to pulmonary congestion.\nOn examination, she was in respiratory distress, her respiratory rate was 30 breaths/min, and her oxygen saturation was 86%. She had a clearly audible pansystolic murmur, and her lung examination was suggestive for pulmonary oedema.\nTransoesophageal echocardiography showed severe MR with practically non-coapting leaflets. An IABP was inserted 24 h prior to the procedure when the patient was euvolemic after diuretic therapy, with the aim of altering LV geometry to optimize the chances of success of MC by improving leaflet coaptation surface length and annular diameter. Baseline average annular diameter on TOE was 48 mm and the average coaptation surface length was 1.8 mm. After insertion of IABP, the average annular diameter decreased to 39 mm and the average coaptation surface length increased to 5.2 mm. Three mitral clips were implanted reducing MR severity from severe to mild-moderate and atrial V-wave from 60 to 25 mmHg (Figure; , Videos S5–S7).\nThe IABP was removed 24 h following the MC procedure after assuring stable haemodynamic and euvolemic status. The patient was discharged a few days later in good condition, with no additional episodes of pulmonary oedema. Three months after discharge, the patient was stable at NYHA functional Class I. Follow-up TTE showed mild-moderate MR and mild-moderate LV systolic function (EF 45%).
The second patient was a 50-year-old woman affected by refractory congestive heart failure due to a post-ischaemic adverse LV remodelling leading to severe functional mitral valve regurgitation with a tethering of posterior mitral leaflet. Six months before, the patient was treated with primary percutaneous coronary intervention (PCI) of left anterior descending artery for a late presentation myocardial infarction with concomitant chronic total occlusion of the right coronary artery. An arrhythmic storm and haemodynamic instability occurred during primary PCI requiring mechanical circulatory support with IABP. At 1 month, after cardiac magnetic resonance imaging showed no residual myocardial viability with an LVEF of 0.18, the patient received an implantable cardioverter-defibrillator. In the following months, the patient was severely symptomatic for dyspnoea (NYHA functional Class IV). Considering the high risk for surgical mitral repair (STS score 7.5%), no need for further revascularization or ventriculoplasty as patient was not considered a candidate for open-heart surgery/heart transplantation, after Heart Team discussion, the patient was planned for MitraClip implantation. The pre-intervention TTE/TOE evaluation confirmed a severe systolic dysfunction (LVEF 0.18), atrial enlargement, diastolic dysfunction, and pulmonary hypertension. Transoesophageal echocardiography showed degenerative leaflets and tethering of the posterior mitral valve leaflet, no evidence of flail leaflets and multiple MR jets between A2-P1 and A2-P3 scallops (). After multidisciplinary discussion, the procedure of PMVR was planned with advanced LV assistance by Impella CP. Similar to previous case, Impella CP implantation was performed with a transfemoral approach, after transseptal puncture and heparinization. A single MitraClip XTR was successfully delivered. Device time including PMVR and Impella CP implantation was 47 min ( and and ). Impella CP was weaned at the end of the procedure and the haemostasis performed by two pre-implanted suture devices (Perclose Proglide; Abbott, Santa Clara, CA, USA). The final TOE/TTE demonstrated an optimal result with residual mild mitral regurgitation (). No complications occurred. In-hospital course was uneventful and the patient was discharged 5 days after index procedure. At 1- and 6-month follow-up, the patient showed an optimal clinical compensation, improvement of symptoms, and functional class (NYHA functional Class II). Transthoracic echocardiography evaluation showed an LVEF of 0.31 (end-diastolic volume: 178 mL; end-systolic volume: 122 mL); a trivial residual mitral regurgitation with an average diastolic gradient of 2 mmHg; an increase stroke volume from 30 to 40 mL; a persistent severe tricuspid regurgitation without pulmonary hypertension evaluated by pulmonary artery acceleration time.