A 69-year-old female patient with a prior history of hypertension, diabetes, hyperlipidaemia, and ischaemic heart disease, who suffered a recent non-reperfused posterior wall myocardial infarction (MI). Transthoracic echocardiography (TTE) showed mildly decreased LV systolic function [LV ejection fraction (EF) 45–50%], moderately dilated left atrium, severe MR with apically tethered leaflets, other causes for decompensation, and murmur including ventricular septal defect (VSD)/papillary muscle rupture, etc. were excluded. She continued suffering from congestive heart failure (CHF) symptoms: rest dyspnoea, no physical capacity, diuretic dependence, and pulmonary congestion.\nOn examination, she was with severe respiratory distress, her respiratory rate was 30 breaths/min, and her lung examination was suggestive for pulmonary oedema, heart sounds were rapid and a harsh pansystolic murmur was audible.\nAlthough the patient was not an optimal candidate for MC and in this effort, an IABP was inserted and left in situ for 24 h in order to optimize haemodynamic status, with the aim of altering LV geometry and to optimize the chances of success of MC by improving the coaptation length. On TOE, the baseline average annular diameter calculated in two orthogonal views, namely the mitral commissural (MC) and long axis was 37 mm. The coaptation surface length calculated in two orthogonal views was 3.9 mm. After insertion of IABP, the average annular diameter decreased to 35 mm and the average coaptation surface length increased to 5.5 mm (Figure; , Videos S1 and S2).\nShe underwent the procedure with no major complications. Two clips were implanted with a decrease of MR grade from +4 to +2 and no evidence of mitral stenosis.\nThe IABP was removed 12 h following the procedure after assuring stable clinical and euvolemic status. The patient was discharged few days later in good condition, with no additional episodes of pulmonary oedema. Three months after discharge, the patient was stable at New York Heart Association (NYHA) functional Class II. Transthoracic echocardiography showed only mild MR with borderline LV systolic function (EF 50%).
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%).