Title:
From Acute Cardiogenic Shock to the Golf Course - A Case of Severe Mitral Regurgitation Treated with Transcatheter Edge to Edge Repair
Introduction:
Cardiogenic shock (CS) associated with severe mitral regurgitation (MR) carries a high risk of morbidity and mortality. These patients are often critically ill with high/prohibitive surgical risk. Transcatheter edge-to-edge repair (TEER) with MitraClip was shown to reduce mortality and heart failure (HF) hospitalizations in hemodynamically stable patients with severe secondary MR on optimally tolerated guideline directed medical therapy (GDMT) in the COAPT trial. However, prospective trials are lacking in hemodynamically unstable patients.
Clinical Case:
An 83-years-old male with prior coronary artery bypass graft with patent grafts, Ross surgery for aortic stenosis, atrial fibrillation, sick sinus syndrome, hypertension, chronic renal insufficiency, diabetes, sleep apnea, and ischemic cardiomyopathy with ejection fraction (EF) of 30%, recent HF hospitalization within a month presented with dyspnea at rest. He was in respiratory distress with trace pedal edema. Serum creatinine was 2.3mg/dl. Chest X-ray revealed pulmonary edema. Diuretics were administered with inadequate response. Transthoracic echocardiogram (TTE) showed severely depressed EF with severe secondary MR (EROA 0.46 cm
2). Right heart catheterization showed cardiac index of 1.4L/min/m² that improved to 1.9L/min/m² following nitroprusside challenge. Milrinone infusion was initiated along with diuretics leading to optimization of volume status but the patient could not be weaned off milrinone due to hypotension. Transesophageal echocardiography (TEE) showed severe secondary MR with the largest jet at the A1-P1 level. Owing to multiple comorbidities, the patient was deemed high-risk for surgical intervention by the heart team and decision was made to proceed with TEER with MitraClip. Under TEE and fluoroscopic guidance, an XTW MitraClip was advanced across the mitral valve and deployed on the A2 and P2 scallops. MR reduced from severe to moderate with mean gradient (MG) of 2mmHg and mitral valve area of 3.24cm
2. A second XT MitraClip was deployed lateral to the first clip and TEE demonstrated further reduction in MR to mild. Final mitral valve MG was 4mmHg. Patient was weaned off Milrinone and GDMT was introduced over next few days. The patient was ultimately discharged to cardiac rehab and then home. At 30-day-follow-up, he was able to participate in physical activities such as golf. Repeat echocardiogram showed stable MitraClip position with mild MR.
Discussion:
CS complicated by severe MR has high morbidity and mortality. With severe MR, the forward stroke volume is lower than stated EF leading to poor organ perfusion and adverse clinical outcomes. CS is treated with inotropes and/or mechanical circulatory support devices. Though these therapies are paramount for initial stabilization, they do not treat the underlying MR. TEER with MitraClip has been shown to improve survival in CS patients with severe MR in observational studies. However, prospective trials are lacking. Our case demonstrates the utility of MitraClip to treat severe secondary MR refractory to medical therapy in a CS patient. Heart teams must carefully evaluate risks and benefits of this therapy in CS patients.