Title:
Percutaneous mitral valve repair in patient with cardiogenic shock requiring mechanical circulatory support. Introduction:
Severe mitral regurgitation (MR) in cardiogenic shock accounts for nearly 7% of patients in the SHOCK registry, and it incurs high mortality and morbidity. In patients with cardiogenic shock complicated by severe MR, mortality is estimated to be 55% before surgical management and 40% despite intervention. These patients have high prohibitive surgical risk and are usually managed medically with the assistance of mechanical circulatory support devices such as intra-aortic balloon pumps to assist in afterload reduction.
Clinical Case:
We describe a case of a 57-year-old gentleman with a past medical history of coronary artery disease with CABG x4 in 2009 with underlying residual disease. He presented to an outside hospital several days before transfer with anterolateral infarction and multiple runs of hemodynamically significant ventricular tachycardia, warranting emergent intervention, with reported cardiac arrest during the procedure. He underwent emergent intubation, eventually having a right groin micro-axial flow pump catheter (Impella
®) placed and started on inotropic support following stenting of his vein–ramus graft, with angiography showing an otherwise patent LIMA. Transthoracic echocardiogram (TTE) showed reduced left ventricular ejection fraction (LVEF) and mild to moderate MR with no evidence of flail. He remained hemodynamically stable while on support, although failed trials of weaning off high Impella
® settings or inotropic doses. Given the suspicion of underestimating his MR, a transesophageal echocardiogram (TEE) was done, showing severe MR involving the P2-P3 scallops with systolic flow reversal in pulmonary veins, and an effective regurgitant orifice area of 0.9 cm2, with persistence on low mechanical support settings. A multidisciplinary discussion resulted in the decision to pursue transcatheter edge-to-edge repair (TEER) with the suspicion that it will likely improve his outcome from the shock standpoint. Successful deployment of 2 mitral clips was achieved, resulting in mild residual MR. He was successfully weaned from mechanical and inotropic support after the procedure, followed by liberation from mechanical ventilation the next day. Goal-directed medical therapy was initiated before discharge, and the patient was discharged in stable condition.
Discussion:
Transcatheter edge-to-edge repair (TEER) has demonstrated significant benefit in improving patients' survival and quality of life with degenerative and functional MR.
However, all clinical trials pertaining to TEER have excluded patients with cardiogenic shock, limiting our understanding of its use in such acute situations. Our case demonstrates successful TEER for acute severe MR in the setting of cardiogenic shock. Few reports demonstrated same result of favorable outcomes in these critically ill patients in terms of improving hemodynamics and the ability to wean inotropic and mechanical circulatory support. Our case adds to a small but growing evidence supporting the use of TEER in unstable patients. We believe that with this evidence will broaden the indications to use TEER in the near future. Further randomized controlled studies are warranted.