An 85-year-old female patient with prior history of hypertension, was urgently admitted to an outside institution with symptoms of progressive dyspnoea and malaise of ∼1 week duration. The patient later revealed all symptoms being preceded by an episode of persistent substernal chest discomfort that she managed at home without contacting her primary physician. In the emergency department, she was found with electrocardiographic evidence of a recent acute myocardial infarction (Q in precordial leads V1–V4 with ST elevations and T-wave inversions). She was diagnosed with an anterior ST-elevation myocardial infarction, pretreated with aspirin 325 mg, and clopidogrel 600 mg and urgently underwent coronary intervention with a drug-eluting stent to an occluded intermediate artery. The rest of the coronary arteries were without stenoses. Echocardiography 24-h later showed akinetic anterior and lateral wall with an estimated ejection fraction of 40%. After initial clinical improvement, the patient abruptly deteriorated on the third day with onset of acute pulmonary oedema and cardiogenic shock. At this time, the electrocardiogram did not show any dynamic changes of the ST-T segments or any arrhythmias. Repeat coronary angiography was without any further stenosis and re-evaluation with echocardiography revealed new severe mitral regurgitation and no other abnormalities that could lead to shock, such as pericardial effusion—tamponade or ventricular septal defect (VSD). Clinical examination at the time revealed an elderly female in moderate distress, requiring supplemental oxygen (60% FiO2) for maintenance of a saturation of 92–93%, with orthopnoea, jugular venous distension, and bilateral inspiratory crackles on lung auscultation. There was a two out of six systolic apical murmur, without evident gallop rhythm and mild peripheral oedema. The patient was transferred to our institution for further management and possible surgery. Upon transfer, she was in New York Heart Association (NYHA) Class IV with persistent pulmonary oedema despite high doses of intravenous furosemide (180 mg/24 h), on high dose supplemental oxygen (60% venturi mask), and on dobutamine infusion at 3 μg/kg/min. A transoesophageal echo exam (TOE) revealed partial rupture of the anterolateral PM with flail anterior (A1 and A2 scallops) and posterior leaflet (P1 scallop) (, , Videos S1 and S2). This PM rupture and flail mitral valve produced severe acute mitral regurgitation, pulmonary oedema, and cardiogenic shock. The patient was evaluated by the heart team and was considered at prohibitive surgical risk [log EuroSCORE 43% (85-years-old female, critical preoperative state/cardiogenic shock, EF 30–50%, recent myocardial infarction) and STS score 13%]. Indeed, she was in intractable heart failure, despite maximal intravenous diuretics, with dyspnoea at rest, radiographic appearance of bilateral pulmonary oedema, and in need of intra-aortic balloon counterpulsation for stabilization. She was thus referred for emergency transcatheter mitral valve edge-to-edge repair with MitraClip (Abbott Vascular, Santa Clara, CA, USA), (, , Video S3). Two clips were implanted at the central and lateral part of the valve. The first clip was implanted at the A2–P2 scallop towards the lateral aspect of the valve. Due to the significant remaining regurgitation coming from the flail anterolateral commissure (, Video S4), a second clip was implanted lateral to the first within the commissure. The final result after implantation of these two clips was with an effective reduction of mitral regurgitation from torrential to mild-moderate, while creating a single orifice valve (‘zipping’ of the lateral commissure) with an estimated (with use of three-dimensional echocardiographic multiplanar reconstruction) residual valve area of 2.1 cm2 and a mean transmitral gradient of 6 mmHg (, , Video S5). Subsequent to the MitraClip procedure, the patient was weaned off both intra-aortic balloon counterpulsation and inotropic support (dobutamine and dopamine infusions). The patient was also switched to oral diuretics and had reduced supplemental oxygen demands. The post-procedural course was uneventful. She was discharged home a week later on standard heart failure therapy including metoprolol, ramipril, furosemide, spironolactone, and ivabradine. At the 20-month follow-up, she remains in stable clinical condition in NYHA class II, and no further interventions were required on the mitral valve. Echocardiography revealed moderate mitral regurgitation and a mean transmitral gradient of 6 mmHg.
The first patient is a 72-year-old woman with severe LV dysfunction related to idiopathic dilated cardiomyopathy leading to heart failure [New York Heart Association (NYHA) function Class IV] despite optimal medical therapy and cardiac resynchronization therapy. She was referred to our tertiary centre due to recurrent rehospitalizations for refractory heart failure. After a first phase of pharmacological treatment or haemodynamic compensation, transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) evaluation confirmed a severely dilated ventricle (LV end-diastolic diameter: 78 mm) associated with a severe LV dysfunction [LV ejection fraction (LVEF): 0.22]. A severe functional mitral regurgitation was revealed (effective regurgitant orifice area: 0.35 cm2, vena contracta: 0.7 cm) due to tethering of the leaflets resulting in multiple jet, the major between A2 and P3 (). The calculated Society of Thoracic Surgeon (STS) score was 8.7%. After Heart Team discussion, transcatheter intervention with MitraClip implantation was planned with advanced LV mechanical circulatory support of Impella CP. The procedure was performed as usual under TOE guidance and general anaesthesia. The Impella CP was inserted, immediately after transseptal puncture and heparinization, through left femoral artery and positioned across the aortic valve with a flow rate of 3 L/min ( and ). Despite the TOE imaging noise generated by the coaxial pump, a MitraClip XTR was successfully implanted (). The final TTE/TOE, with Impella CP running at the lowest performance level, demonstrated an optimal result with residual mild mitral regurgitation with an average diastolic gradient of 2 mmHg and peak diastolic gradient of 5 mmHg (). The entire procedure was performed with Impella CP assistance, which guaranteed the LV unload during the procedure. Device time including PMVR and Impella CP implantation was 38 min. Impella CP support was left in place and active. In the following hours, progressive improvement of the patient’s haemodynamic performance occurred and Impella CP support was weaned until the removal of the device. Haemostasis was guaranteed by two pre-implanted suture closure devices (Perclose Proglide; Abbott, Santa Clara, CA, USA). In-hospital course was uneventful and the patient was discharged 6 days after the index procedure with good haemodynamic compensation.\nAt 1- and 6-month follow-up, the patient showed improved symptoms and functional class (NYHA functional Class II). The TTE evaluation showed an improvement of LV systolic function (LVEF 0.27) and confirmed the post-procedural result showing a residual mild mitral regurgitation (regurgitant volume of 12 mL).