2023 SCAI SHOCK

Emergent M-TEER in Rescuing Cardiogenic Shock from Acute Degenerative Primary MR

Presenter

Husam Shadid, MD, The University of Texas Health Science Center at Houston, Houston, TX
Husam Shadid, MD, The University of Texas Health Science Center at Houston, Houston, TX

Title

Emergent M-TEER in Rescuing Cardiogenic Shock from Acute Degenerative Primary MR

Introduction

Cardiogenic shock (CS) secondary to acute severe mitral regurgitation (MR) is associated with high morbidity and mortality. Despite the growing volume of literature on mitral valve transcatheter edge-to-edge repair (M-TEER) as a procedural treatment for CS complicated by severe ischemic MR after acute myocardial infarction (AMI), limited information exists regarding primary MR from degenerative changes. This case highlights the significance of M-TEER in addressing CS linked to acute MR stemming from primary myxomatous mitral valvular changes.

Clinical Case

We present a 67-year-old African American woman with extensive multivessel calcific coronary artery disease and short LIMA who underwent bypass grafts (LIMA-OM, SVG-LAD, SVG-PDA). Six months later she again had angina and was discovered to have occluded venous grafts to the LAD and PDA as well as an atretic LIMA to OM. She was treated with DES placement in the RCA and LAD. Three months later, she was admitted to an outside facility with chest pain, and dyspnea.

There, evaluation revealed markedly elevated pulmonary capillary wedge pressure and pulmonary hypertension secondary to severe MR. An IABP was placed for mechanical cardiac support and she was transferred to our center. TTE showed an EF of 50%, moderate eccentric MR, and LVESD of 3.8 cm. A TEE demonstrated degenerative, myxomatous mitral valve leaflets with eccentric, severe 4+ MR involving three distinct jets. .

The patient was deemed to be high surgical risk with a STS mortality risk score of 9.5%. She was not a candidate for LVAD or transplant in context of her non-dilated left ventricle (LVEDD 5.5 cm) and poor social support. She . Initial residual MR prompted a second MitraClip XTW placement more laterally, achieving a substantial reduction in regurgitation.

Discussion

Severe MR leading to CS carries a substantial mortality risk. The advent of M-TEER provides a promising solution for patients deemed high surgical risk who fall beyond the EVEREST and COAPT criteria. The existing literature, comprising case reports, series, and observational studies such as the MITRA-SHOCK multicenter study, have highlighted the favorable procedural success rates and safety profile associated with M-TEER in this context.

Our presented case further contributes to this growing body of evidence, demonstrating the applicability of M-TEER as a salvage option for patients in CS secondary to degenerative primary severe MR. There is no algorithmic guideline for managing CS secondary to severe MR. While mechanical cardiac support as a bridge to surgical intervention can be considered, many patients are not surgical candidates. We believe that patients with severe mixed mitral valve disease and normal LV dimensions in CS with hemodynamics to prove MR as cause are well suited for M-TEER as treatment, but further data is necessary.