A Tale of Two Mitral Clips: Mitral-TEER in Late Presenting STEMI with Acute Mitral Regurgitation and Cardiogenic Shock
Presenter
Maninderjit Ghotra, MD, Icahn School of Medicine at Mount Sinai Morningside, New York, NY
Maninderjit Ghotra, MD1, Samuel Tan, MD1, Marko Novakovic, MD1, Paulus Adinugraha, MBBS1, Sara Diaz, MD1, Vincent Torelli, DO1, Lexi Robbins1, Katharine Idrissi, MSN1, Basera Sabharwal, MD1 and Matthew I Tomey, M.D., FSCAI2, (1)Icahn School of Medicine at Mount Sinai Morningside, New York, NY, (2)Icahn School of Medicine at Mount Sinai, New York, NY
Title
A Tale of Two Rescue Clips: Mitral-TEER in Late Presenting STEMI with Acute Mitral Regurgitation and Cardiogenic Shock Introduction
Patients with ST-segment elevation myocardial infarction (STEMI) who present late without primary reperfusion therapy are at elevated risk for mechanical complications, shock, and mortality. Acute mitral regurgitation (MR) can contribute to critical illness in some patients. For patients deemed prohibitively ill for surgery, transcatheter edge-to-edge repair (TEER) may offer means to mitigate MR, but outcomes are incompletely understood. We report here two cases with discordant outcomes. Clinical Case
A 91-year-old female presented to a percutaneous coronary intervention (PCI)-capable spoke hospital with dyspnea, inferior Q waves with associated ST-segment elevations, and initial high-sensitivity troponin I above assay limits. Coronary angiography disclosed thrombotic occlusion of the proximal left circumflex artery. PCI was deferred. Echocardiography showed new severe MR. The patient transferred to a shock hub hospital, where pulmonary artery catheterization disclosed central venous pressure 10 mmHg, pulmonary artery pressure 48/22 mmHg, cardiac output 1.9 L/min with index 1.2 L/min/m2, and pulmonary capillary wedge pressure 22 mmHg with large V waves. Intra-aortic balloon pump (IABP) was placed with improvement in hemodynamics, followed by successful mitral TEER using one MitraClip™
XTW. Intervention occurred 1 day after initial hospital presentation. The patient improved clinically and hemodynamically permitting weaning off all vasoactive drugs and IABP support. Four days post-procedure, however, she abruptly arrested with findings of pulseless electrical activity, hemopericardium and left ventricular free wall rupture. An 80-year-old male presented to a PCI-capable spoke hospital with atrial fibrillation, dyspnea, inferior Q waves, initial high-sensitivity troponin I exceeding assay limits, inferior akinesis on echocardiogram and severe MR due to restriction of the posterior leaflet. Coronary angiography showed single-vessel disease with occlusion of the distal right coronary artery. IABP was placed with transfer to a shock hub hospital, where pulmonary artery catheterization disclosed central venous pressure 6 mmHg, pulmonary artery pressure 46/13 mmHg, cardiac output 2.7 L/min with index 1.6 L/min/m2, and pulmonary capillary wedge pressure 16 mmHg with large V waves. Following heart team discussion and a period of supportive care, the patient underwent successful mitral TEER using one MitraClip™
NTW device with improved hemodynamics. Intervention occurred 23 days after initial hospital presentation. The patient recovered permitting discharge on guideline-directed medical therapies. Discussion
Acute ischemic MR can contribute to pathogenesis of shock in patients with late-presenting STEMI. Vasoactive drugs may be insufficient—and even counterproductive—in such cases to stabilize hemodynamics and promote recovery. Temporary mechanical circulatory support may help temporize hemodynamics while evaluating candidacy for valve intervention. Where surgery is deemed prohibitive, TEER can be technically feasible to ameliorate MR in select patients. These cases remind us, however, that mitigating MR does not eliminate all risk associated with late-presenting STEMI. Paralleling lessons from surgical literature, those patients who survive initial phases of recovery may be more likely to do well after later TEER. Implications of early mitral TEER for left ventricular geometry, hemodynamics, and propensity to rupture after STEMI are unknown and warrant further study.