Title
A Young Patient Suffering from Acute Myocardial Infarction Complicated by Cardiogenic Shock and Severe Mitral Regurgitation Introduction
Acute ischemic mitral regurgitation (MR) due to sudden systolic leaflet tethering related to the sudden onset of regional or global left ventricular dysfunction can present with severe MR with pulmonary edema and cardiogenic shock (CS). We present the case of a patient with acute myocardial infarction complicated by severe MR and CS treated initially by conventional measures and ultimately with transcutaneous edge-to-edge repair (TEER).
Clinical Case
51-year-old male, without known cardiovascular comorbidities. Presented to another hospital with anterior ST elevation myocardial infarction (STEMI). He underwent percutaneous coronary intervention (PCI) with stent implantation to LM-LAD. He recovered and was discharged from hospital after a few days. Two weeks later, repeat hospitalization with acute heart failure and pulmonary edema. On echocardiography, severe left ventricular dysfunction (LVD) with new severe MR. The patient was then transferred to our hospital. On arrival at our hospital, the patient present with CS and pulmonary edema. The patient was intubated with mechanical respiratory support and was taken to the cath lab. On angiogram the LM stent was open, but stent thrombosis was found in the LAD with total occlusion. PCI was attempted but was unsuccessful, and an intra-aortic balloon pump (IABP) was left in place. Repeat echocardiography showed further worsening of LV function with severe MR with eccentric jet. Due to refractory CS with mechanical support and very high surgical risk, the heart team decided to proceed with TEER. The patent underwent the procedure with one clip implantation achieving reduction of MR by two grades, with improved hemodynamic parameters. The patient was weaned from the IABP and pressor support the following day. Two days later he was extubated and weaned from mechanical ventilation and was discharged. The patient is still alive. At 30-day follow-up he had no repeat hospitalization and only one hospitalization at 6-month follow-up.
Discussion
We present a case of cardiogenic shock with severe MR ultimately treated with TEER. The patient's initial insult was AMI treated PCI. He developed a stent thrombosis at an unknown time, most likely around the time of his second hospitalization. The second ischemic insult, with the subsequent development of acute ischemic MR, resulted in CS and pulmonary edema. The patient was at category D based on SCAI shock criteria with deteriorating parameters, despite vasopressor and mechanical support. At that stage of deterioration, we felt that MR was a major component of the shock causing a vicious cycle with refectory pulmonary edema and decided to correct the MR. Due to prohibitive surgical risk, TEER was performed. The 30-day mortality rate in CS is around 50%. In patients suffering from CS with severe MR, the prognosis can be even worse and without any definitive therapy directed at the valve, mortality rates are extremely high. Since many patients are deemed inoperable, the important role of less invasive options is emphasized.
This case supports the role of TEER in the acute setting which can be a safe and effective therapeutic option.