Percutaneous edge-to-edge treatment of an acute mitral regurgitation in a patient with late-presenting STEMI complicated by cardiogenic shock
Presenter
Saverio Continisio, M.D., The University of Padua, Padua, Italy
Saverio Continisio, M.D.1, Giulo Rodinò2, Luca Nai Fovino, M.D.3, Giulia Masiero4, Chiara Fraccaro, MD5, Massimo Napodano4, Francesco Cardaioli4, Carolina Montonati4 and Giuseppe Tarantini, MD, PhD6, (1)The University of Padua, Padua, Italy, (2)University of Padova, Padua, Italy, (3)The University of Padua, Padova, Italy, (4)University of Padova, Padova, Italy, (5)-, Padova, Italy, (6)The University of Padua, Padova, PD, Italy
Keywords: Cardiogenic Shock, Hemodynamic Support, Structural Heart Disease (SHD) and TEER/TMVR/Mitral Valve
Background
We present the case of a 46-year-old patient admitted to our ward with late-presenting STEMI and severe mitral regurgitation (MR). He had a history of Hodgkin lymphoma during childhood, treated with radiotherapy. Due to impending cardiogenic shock, he underwent emergent coronary angiography with evidence of acute occlusion of Cx artery and 3-vessel coronary artery disease. During the procedure, the patient experienced a cardiac arrest due to PEA, early reversed by CPR and inotropic drugs administration. After induction of anesthesia and orotracheal intubation, we decided to perform multivessel PCI with Impella CP support. The patient was then transferred to the ICU, were he remained sedated and mechanically ventilated and with labile hemodynamic compensation.
Methods
On the first day after the procedure, a TOE showed severe systolic dysfunction of the LV with severe ischemic mitral regurgitation and evidence a cleft of P2 scallop, in addiction. Furthermore, due to post-actinic esophagitis and concomitant need for anti-thrombotic therapy, he suffered esophageal bleeding requiring multiple blood transfusions and invasive treatment. Weaning from both pharmacological and Impella support proved unfeasible, due to labile patient’s hemodynamics. After multidisciplinary evaluation it was decided to perform a percutaneous mitral valve repair with the MitraClip system.
Results
A single MitraClip XTR was positioned between A2 and P3 scallops, obtaining a moderate residual MR with a mean gradient of 3.75 mmHg. Positioning of a second clip was attempted, but resulted in higher gradient and the clip was not deployed. Nevertheless, a significant hemodynamic improvement was observed, which allowed the removal of the Impella.
Conclusions
The following day the patient showed no neurological defects and was successfully extubated. Inotropic support was withdrawn 2 days after procedure. After a short, the patient was transferred to the surgical department and underwent major surgical procedure to investigate a para-esophageal mass, without hemodynamic decay or other adverse events. A TTE performed before discharge (total hospitalization: 61 days) revealed a significant improvement of and good result of MitraClip implantation.