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 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.