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.
An 80-year-old female patient with a prior history of hypertension, hyperlipidaemia, diabetes, and ischaemic heart disease with a prior inferior MI and PCI with drug-eluting stent placement to LCX, 3 years prior to her current admission. She was admitted with respiratory failure due to pulmonary oedema and pneumonia.\nThe patient was conscious, intubated, and ventilated with remarkable tachypnoea, her blood pressure was 80/50 mmHg and her pulse 100 b.p.m. There were decreased lung sound in both bases, heart sounds were irregular and fast, periphery was cold and dry.\nInitial TTE upon admission showed normal size LV with normal global systolic function, severe ischaemic MR (posteriorly directed wall jet), and no stenosis. After a 10-day period with improvement of infectious status, but no improvement in her CHF signs and inability to wean from mechanical ventilation due to continuous pulmonary congestion, a decision was made to perform urgent mitral clipping as salvage therapy. Prior to the procedure, TOE was performed that showed severe MR with a posteriorly directed jet, severe malcoaptation mainly resulting from posterior leaflet immobility, and no evidence of papillary muscle rupture or new VSD. Mitral valve measurements were based on TOE prior to the procedure: average annular diameter was 40 mm and average coaptation surface length was 2.9 mm. An IABP was inserted 3 days prior to the procedure as means of haemodynamic support and aim of altering LV geometry to optimize the chances of success of MC by improving leaflet coaptation surface length and annular diameter. Transoesophageal echocardiography after insertion of IABP showed an average annular diameter of 36 mm and average coaptation surface length was 5.2 mm. Two MCs were implanted (one medially and one laterally to the prominent calcification). Mitral regurgitation improved from severe to moderate and atrial V-wave decreased from 60 to 25 mmHg, with no immediate post-procedural complications.\nFollowing the procedure there was an initial improvement in in her respiratory condition, the IABP was kept in situ to allow better haemodynamic and vulemic support. Unfortunately 7 days after the procedure, she developed ventilator associated pneumonia and sepsis with multiorgan failure, she died 10 days following the procedure.