A 74-year-old female patient with a prior history of hypertension, hyperlipidaemia, diabetes, asthma, chronic renal failure, and ischaemic heart disease. Two months prior to her admission, she was treated in the cardiac intensive care unit for inferior-lateral ST-elevation myocardial infarction and underwent percutaneous coronary intervention (PCI) to the left circumflex (LCX) artery.\nOn examination, she was in respiratory distress (25 breaths/min) and her oxygen saturation was 86% on room air. Upon auscultation, she had a clear audible systolic murmur radiating to her left axilla, had diminished lung sounds in the bases and crackles suggestive for pulmonary oedema.\nThe patient did not improve despite maximal medical therapy and remained in NYHA Classes III–IV. Transoesophageal echocardiography showed severe MR with practically no leaflet coaptation (‘Free MR’), and other causes for severe MR (VSD/papillary muscle rupture, etc.) were excluded. Prior to the procedure an IABP was placed for 48 h to help maintain clinical stability and euvolemic status, and to achieve LV geometry alteration thus allowing better leaflet coaptation to optimize MC success. Mitral valve measurements using TOE showed an average annular diameter of 42 mm, and coaptation surface length of 1.9 mm. After insertion of IABP, the average annular diameter was 34 mm and the average coaptation surface length was 4.4 mm (Figure); see , Videos S3 and S4). The patient underwent implantation of three MCs, with a good overall results and improvement of the MR from severe to mild-moderate.\nFollowing the MC procedure for 48 h, the patient was weaned from the IABP after assuring stable haemodynamic status. The patient was discharged a few days later in good condition, with major improvement in NYHA symptoms and no additional episodes of pulmonary oedema. Three months after discharge, the patient was stable at NYHA Class II. Follow-up TTE showed moderate MR with moderately reduced LV function (EF 40%).
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).