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 85-year-old female patient with prior history of hypertension, was urgently admitted to an outside institution with symptoms of progressive dyspnoea and malaise of ∼1 week duration. The patient later revealed all symptoms being preceded by an episode of persistent substernal chest discomfort that she managed at home without contacting her primary physician. In the emergency department, she was found with electrocardiographic evidence of a recent acute myocardial infarction (Q in precordial leads V1–V4 with ST elevations and T-wave inversions). She was diagnosed with an anterior ST-elevation myocardial infarction, pretreated with aspirin 325 mg, and clopidogrel 600 mg and urgently underwent coronary intervention with a drug-eluting stent to an occluded intermediate artery. The rest of the coronary arteries were without stenoses. Echocardiography 24-h later showed akinetic anterior and lateral wall with an estimated ejection fraction of 40%. After initial clinical improvement, the patient abruptly deteriorated on the third day with onset of acute pulmonary oedema and cardiogenic shock. At this time, the electrocardiogram did not show any dynamic changes of the ST-T segments or any arrhythmias. Repeat coronary angiography was without any further stenosis and re-evaluation with echocardiography revealed new severe mitral regurgitation and no other abnormalities that could lead to shock, such as pericardial effusion—tamponade or ventricular septal defect (VSD). Clinical examination at the time revealed an elderly female in moderate distress, requiring supplemental oxygen (60% FiO2) for maintenance of a saturation of 92–93%, with orthopnoea, jugular venous distension, and bilateral inspiratory crackles on lung auscultation. There was a two out of six systolic apical murmur, without evident gallop rhythm and mild peripheral oedema. The patient was transferred to our institution for further management and possible surgery. Upon transfer, she was in New York Heart Association (NYHA) Class IV with persistent pulmonary oedema despite high doses of intravenous furosemide (180 mg/24 h), on high dose supplemental oxygen (60% venturi mask), and on dobutamine infusion at 3 μg/kg/min. A transoesophageal echo exam (TOE) revealed partial rupture of the anterolateral PM with flail anterior (A1 and A2 scallops) and posterior leaflet (P1 scallop) (, , Videos S1 and S2). This PM rupture and flail mitral valve produced severe acute mitral regurgitation, pulmonary oedema, and cardiogenic shock. The patient was evaluated by the heart team and was considered at prohibitive surgical risk [log EuroSCORE 43% (85-years-old female, critical preoperative state/cardiogenic shock, EF 30–50%, recent myocardial infarction) and STS score 13%]. Indeed, she was in intractable heart failure, despite maximal intravenous diuretics, with dyspnoea at rest, radiographic appearance of bilateral pulmonary oedema, and in need of intra-aortic balloon counterpulsation for stabilization. She was thus referred for emergency transcatheter mitral valve edge-to-edge repair with MitraClip (Abbott Vascular, Santa Clara, CA, USA), (, , Video S3). Two clips were implanted at the central and lateral part of the valve. The first clip was implanted at the A2–P2 scallop towards the lateral aspect of the valve. Due to the significant remaining regurgitation coming from the flail anterolateral commissure (, Video S4), a second clip was implanted lateral to the first within the commissure. The final result after implantation of these two clips was with an effective reduction of mitral regurgitation from torrential to mild-moderate, while creating a single orifice valve (‘zipping’ of the lateral commissure) with an estimated (with use of three-dimensional echocardiographic multiplanar reconstruction) residual valve area of 2.1 cm2 and a mean transmitral gradient of 6 mmHg (, , Video S5). Subsequent to the MitraClip procedure, the patient was weaned off both intra-aortic balloon counterpulsation and inotropic support (dobutamine and dopamine infusions). The patient was also switched to oral diuretics and had reduced supplemental oxygen demands. The post-procedural course was uneventful. She was discharged home a week later on standard heart failure therapy including metoprolol, ramipril, furosemide, spironolactone, and ivabradine. At the 20-month follow-up, she remains in stable clinical condition in NYHA class II, and no further interventions were required on the mitral valve. Echocardiography revealed moderate mitral regurgitation and a mean transmitral gradient of 6 mmHg.