Entangled: Development of Primary Mitral Regurgitation after Impella Explantation
Debapria Das, Saint Louis University, St. Louis, MO
Debapria Das1, Issam Atallah, MD2, Niteesh Chitturu1, William Frick1, Yash Nayak2, Steven Smart, M.D.3, Anne Cahill2, Sunil Prasad, M.D.4, Kishore J. Harjai, M.D., FSCAI5 and Divya Ratan Verma, M.D.6, (1)Saint Louis University, St. Louis, MO, (2)Saint Louis University Hospital, Saint Louis, MO, (3)Unaffiliated, Chicago, IL, (4)University of Rochester Medical Center, Rochester, NY, (5)Saint Louis University, Saint Louis, MO, (6)Banner - University Medical Center Phoenix, Phoenix, AZ
Keywords: Cardiogenic Shock and Complications
Title
Entangled: Development of Primary Mitral Regurgitation after Impella Explantation
Introduction
Iatrogenic injury of the mitral valve apparatus is a rare complication after Impella placement. We present a case of worsening mitral regurgitation after Impella removal used as a treatment for cardiogenic shock.
Clinical Case
A 59 year old male with a past medical history of hypertension with cocaine and PCP use presents to the hospital new onset heart failure. Initial echocardiogram showed a dilated left ventricle with EF 10% and mildly reduced right ventricular function. There was moderate to severe mitral regurgitation. Patient was transferred to the ICU due to hypotension requiring pressor support. Left heart catheterization showed nonobstructive disease. Right heart catheterization revealed elevated biventricular pressures, cardiac index of 1.36 L/min/m2, cardiac power output of 0.55, and pulmonary pulsatility index of 1.7 while on inotropes and pressors. An Impella CP was placed with echo confirming appropriate placement. The Impella had to be repositioned under echo guidance two times due to displacement towards the mitral valve showing entanglement with chordae before explantation 8 days later. Subsequent transesophageal echo showed a flail A3 scallop due to ruptured chordae with new torrential MR with an effective regurgitant orifice by PISA 1.68 cm2, regurgitant volume of 194 mL and regurgitant fraction of 71%. After a heart team discussion, patient underwent a MitraClip which reduced the regurgitant volume by 75%, however his mitral regurgitation remained severe. The patient continued to have dyspnea at rest requiring high flow nasal cannula and persistent inotrope and pressor support. After surgical re-evaluation, patient was taken for mitral valve replacement with a 29mm bioprosthetic valve and tricuspid valve repair with Impella 5.5 support. Post-op patient developed RV failure and was placed on VA ECMO. Patient stabilized afterwards and was weaned off VA ECMO on post-op day 12 and Impella on day 14. He was discharged 39 days after his initial presentation with tracheostomy, percutaneous endoscopic gastrostomy tube, and dialysis.
Discussion
In our case, the etiology of this patients worsening MR was likely secondary to entanglement of the Impella inlet as an ischemic etiology was unlikely given no significant disease on the left heart catheterization. As repositioning was performed under echocardiographic guidance, review of the images allowed prompt management after discussion with the heart team. It is imperative that the Impella catheter is secured in order to avoid dislodgement leading to iatrogenic injury of the mitral or aortic valve. Management of primary mitral regurgitation may include percutaneous procedures or surgical replacement.