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%).
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.