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%).
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).