2023 SCAI SHOCK

Can “Unplugging Clogged Pipes” in the Heart Worsen the “Leak”???

Presenter

Krutarth Kandarp Pandya, Cleveland Clinic Main Campus, Cortland, OH
Krutarth Kandarp Pandya, Cleveland Clinic Main Campus, Cortland, OH and Riya Patel, Western Reserve Health Education, Warren, OH

Title:
Can “Unplugging Clogged Pipes” in the Heart Worsen the “Leak”???

Introduction:
It has been studied that Mitral Regurgitation (MR) is a poor prognostic factor in patients undergoing coronary revascularization for Acute MI. Here we present 2 cases with significant Ischemic Cardiomyopathy burden and MR on presentation whose MR got significantly worse after 3-5 days of coronary artery revascularization leading to Acute Heart Failure (AHF) and Cardiogenic Shock (CS).

Clinical Case:
Case 1:
An 82-year-old man with a Past Medical History of Hypertension presented with chest discomfort and shortness of breath. He was found to have Acute Coronary Syndrome (ACS) and AHF with a multi-vessel disease on angiogram with Left Main (LM), Left Anterior Descending (LAD), and Right Coronary Artery (RCA) involvement. With the Heart Team approach, he went for high-risk PCI, and Drug Eluting Stent (DES) placement. The echocardiogram showed 32% EF with moderate MR. Hemodynamic improvement was observed while he was being managed for AHF in CCU. On Day 3 of revascularization, he decompensated with AHF again, and repeated Echocardiogram showed worsening of severe MR but significantly improved EF of 50%. Afterload reduction was attempted with Sodium Nitroprusside with borderline blood pressure and he was transferred to the tertiary care center for urgent TEER with Clip implantation. Unfortunately, he could not make it because of his age and multiple comorbidities, and he expired.

Case 2: A 71-year-old man presented with known coronary artery disease presented with chest pain. He was found to have ACS with a multi-vessel disease on coronary angiogram with LM, LAD involvement, and known RCA chronic total occlusion. He had poor targets and hence he could not go for CABG. He went for high-risk PCI, with DES and Intra-Aortic Balloon Implantation (IABP) placement with CS requiring Norepinephrine (NE) and Milrinone drips. The echocardiogram showed 42% EF with moderate MR. Hemodynamics improved while he was being managed for AHF and CS, and eventually, he was able to come off of drips and weaned off of IABP as well. Subsequently, after the removal of IABP, he developed clinical deterioration and required NE again for hemodynamic instability. On repeat Echocardiogram, worsening of MR with significantly improved EF of 72% was seen. On repeat angiogram, no new coronary blockages were seen and IABP was placed again. For further afterload reduction, Sodium Nitroprusside drip was initiated which helped to wean off of NE dramatically. Urgent Transcatheter Edge-to-Edge Repair (TEER) was performed with a Clip placement and he was weaned off the drips again and discharged to rehab after a prolonged ICU stay.

Discussion:
MR in patients with ischemic cardiomyopathy can worsen significantly after revascularization leading to AHF and CS. Extensive surveillance of MR (Ischemic vs. Structural) in patients with ACS along with close monitoring, and appropriate measures to prevent/manage further decompensation are required. Further studies are needed to look for patients at risk using Echocardiographic and hemodynamic measures.