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.
A 74-year-old female patient with a prior history of hypertension, hyperlipidaemia, diabetes, asthma, chronic renal failure, and ischaemic heart disease. Two months prior to her admission, she was treated in the cardiac intensive care unit for inferior-lateral ST-elevation myocardial infarction and underwent percutaneous coronary intervention (PCI) to the left circumflex (LCX) artery.\nOn examination, she was in respiratory distress (25 breaths/min) and her oxygen saturation was 86% on room air. Upon auscultation, she had a clear audible systolic murmur radiating to her left axilla, had diminished lung sounds in the bases and crackles suggestive for pulmonary oedema.\nThe patient did not improve despite maximal medical therapy and remained in NYHA Classes III–IV. Transoesophageal echocardiography showed severe MR with practically no leaflet coaptation (‘Free MR’), and other causes for severe MR (VSD/papillary muscle rupture, etc.) were excluded. Prior to the procedure an IABP was placed for 48 h to help maintain clinical stability and euvolemic status, and to achieve LV geometry alteration thus allowing better leaflet coaptation to optimize MC success. Mitral valve measurements using TOE showed an average annular diameter of 42 mm, and coaptation surface length of 1.9 mm. After insertion of IABP, the average annular diameter was 34 mm and the average coaptation surface length was 4.4 mm (Figure); see , Videos S3 and S4). The patient underwent implantation of three MCs, with a good overall results and improvement of the MR from severe to mild-moderate.\nFollowing the MC procedure for 48 h, the patient was weaned from the IABP after assuring stable haemodynamic status. The patient was discharged a few days later in good condition, with major improvement in NYHA symptoms and no additional episodes of pulmonary oedema. Three months after discharge, the patient was stable at NYHA Class II. Follow-up TTE showed moderate MR with moderately reduced LV function (EF 40%).