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).
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.