|Year : 2023 | Volume
| Issue : 1 | Page : 50-53
MitraClip to the rescue in cardiogenic shock: Case series from a single center
Ashraf Omer Elamin Ahmed1, Nazar Mohammed2, Hakam Abdallah Alzaeem3, Syed Muhammad Saad Jalil4, Cheikh Abdoul Maaly3, Mohammed Al-Hijji2
1 Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
2 Department of Interventional Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
3 Department of Echocardiography, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
4 Weill Cornell Medicine, Doha, Qatar
|Date of Submission||22-Sep-2022|
|Date of Acceptance||22-Jan-2023|
|Date of Web Publication||23-Feb-2023|
Dr. Mohammed Al-Hijji
MD, FACC Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Cardiogenic shock (CS) in the setting of acute coronary syndrome carries detrimental consequences and high levels of mortality and morbidity if not managed promptly. Acute mitral regurgitation (MR) as a complication of the myocardial infarction might superimpose refractory CS that warrants mitral valve repair. There has been growing use of Transcatheter edge-to-edge mitral valve repair (TEER) as a therapy for CS secondary to acute MR. In this cohort, we describe two cases of CS secondary to acute ischemic MR managed with a Mitraclip.
Keywords: Cardiogenic shock, MitraClip, mitral regurgitation
|How to cite this article:|
Ahmed AO, Mohammed N, Alzaeem HA, Jalil SM, Maaly CA, Al-Hijji M. MitraClip to the rescue in cardiogenic shock: Case series from a single center. Heart Views 2023;24:50-3
|How to cite this URL:|
Ahmed AO, Mohammed N, Alzaeem HA, Jalil SM, Maaly CA, Al-Hijji M. MitraClip to the rescue in cardiogenic shock: Case series from a single center. Heart Views [serial online] 2023 [cited 2023 Dec 7];24:50-3. Available from: https://www.heartviews.org/text.asp?2023/24/1/50/370268
| Introduction|| |
Despite advances in detection algorithms, percutaneous mechanical devices, and management pathways, cardiogenic shock (CS) in the setting of the acute coronary syndrome is associated with a high in-hospital mortality rate of around 35%–50%.
Mitral regurgitation (MR) is the most common valvular disease and causes CS in the setting of acute myocardial infarction by reducing forward stroke volume, which in turn increases left atrial pressure and volume. Transcatheter mitral valve edge-to-edge repair (MTEER) using Mitraclip device (Abbott) has been shown to significantly reduce the heart failure hospitalization rate and mortality rate compared to medical therapy alone when used for functional mitral valve regurgitation. However, these trials did not include patients with CS related to acute MR.
In this case series, we describe the utility of MTEER with Mitraclip as a treatment for CS secondary to acute ischemic MR.
| Cases Reports|| |
A 52-year-old man presented with anterior ST-elevation myocardial infarction (STEMI). He was found to be in the CS Society for Cardiovascular Angiography and Interventions (SCAI) C. He was started on vasopressors and inotropes. The patient was initially treated with systemic thrombolysis at a peripheral hospital with symptom improvement and reduction of more than 50% in ST segments elevation, and then he was transferred to our center.
Coronary angiography (CAG) was done within 24 h of the symptoms and showed complete occlusion of the proximal left anterior descending artery (LAD) and subtotal left circumflex occlusion. Manual thrombus aspiration was performed, followed by overlapping drug-eluting stents to proximal to middle LAD. PCI with a drug-eluting stent to the distal left circumflex was done. An intra aortic balloon pump (IABP) was inserted for SCAI stage C CS while norepinephrine and levosimendan infusion was continued.
Bedside transthoracic echocardiography showed EF of 31%, stroke volume of 29 ml, and grade 4 functional MR effective with effective regurgitant orifice area (EROA) of 0.40 m2, and MR volume of 34 ml [Video 1a and b]. After diuresis and weaning from IABP and levosimendan on day 4, the patient continued to have poor forward flow and was dependent on norepinephrine with an inability to increase afterload agents. On day 9, the patient went into pulmonary edema, requiring an oxygen supplement, 3–4 l, through the nasal cannula. The patient continued to be in SCAI C CS, requiring norepinephrine and dopamine infusion.
[Additional file 1]
[Additional file 2]
After a multidisciplinary team (MDT) discussion with the patient and the family, it was decided that mitral valve repair is essential for patient survival. Given his high risk for urgent surgical valve repair, the patient went for MTEER. Two clips (NTW ×2) were placed, the first clip was in A2/P2, and the second clip was medial to it to treat the residual medial jet. The MR grade was reduced from grade 4 to grade 2. The patient had immediate resolution of pulmonary vein systolic reversal and improvement of LA pressure ("v" wave pre – 50 mmHg to post-20 mmHg and mean LA pre-35 mmHg to post-20 mmHg) [Figure 1]a and [Figure 1]b. After the procedure, the vasopressors and inotropes were completely weaned off, and his medications were optimized. He was discharged on aspirin, ticagrelor, rosuvastatin, bisoprolol, furosemide, ivabradine, empagliflozin, valsartan, and spironolactone.
|Figure 1: (a) Pre-MTEER left atrial pressure graph showing high left atrial pressure. (b) Post-MTEER left atrial pressure graph showing significant reduction in the left atrial pressure|
Click here to view
The patient was asymptomatic with the New York Heart Association (NYHA) I during his last follow-up at 2 weeks of discharge.
A 62-year-old man with a past medical history of diabetes and hypertension was admitted as a case of non-STEMI, complicated by CS SCAI C and diabetic ketoacidosis (DKA). The patient was intubated due to type one respiratory failure and started on epinephrine, dopamine, and the DKA management protocol.
CAG was done, showing left main stenosis of 80%, diffuse proximal LAD stenosis of 90%, proximal left circumflex of 80% thrombotic occlusion, and OM1 100% thrombotic occlusion. POBA was performed on the left circumflex to reestablish flow. Given the presentation of multivessel disease with left main involvement, the case was discussed with the cardiothoracic surgery team, and he was deemed unfit for bypass surgery. A few days later, he was extubated, and the DKA was resolved; however, he required vasopressors.
Percutaneous revascularization was performed with two overlapping drug-eluted stents provisionally placed from left main to mid LAD. Transthoracic echocardiography showed EF of 27%, severely high LA pressure, grade 3+ ischemic MR EROA of 0.28 m2, and a regurgitant volume of 39 ml [Video 2a and b]. The patient had pulmonary edema and right pleural effusion that required therapeutic paracentesis, requiring 3–4 l of oxygen through a nasal cannula, furosemide, and epinephrine.
[Additional file 3]
[Additional file 4]
As his mitral valve regurgitation did not improve after PCI, the case was discussed in MDT, and eventually, he was considered for an MTEER. One mitral clip (NTW) was placed in A2/P2 position with immediate LA pressure improvement ("v" wave pre-50 mmHg to post-19 mmHg and mean pre-27 to post-11).
MR improvement from grade 3+ to grade 1 [Figure 2]a and [Figure 2]b. The epinephrine was weaned off, and the patient improved significantly after the procedure. He was discharged on (aspirin, clopidogrel, atorvastatin, bisoprolol, dapagliflozin, valsartan, spironolactone, furosemide, and digoxin). In 1 week follow-up, he had postural hypotension, and his medication doses were further optimized. He was last seen in the clinic 4 months later, and he was minimally symptomatic NYHA II. He did not have recurrent admission for heart failure or MI.
|Figure 2: (a) Pre-MTEER left atrial pressure graph showing high left atrial pressure. (b) Post-MTEER left atrial pressure graph showing significant reduction in the left atrial pressure|
Click here to view
| Discussion|| |
CS is a life-threatening condition that occurs commonly after myocardial infarction. Ischemic insults account for 80% of CS; less commonly, mechanical consequences such as acute MR, as a complication of myocardial infarction, cause about 7% of CS., Early management is crucial in CS; besides oxygenation, mechanical ventilation, circulatory supports with IV fluids, vasopressors, inotropes, and mechanical circulatory support devices, the underlying etiology should be fixed if found.,
MR, particularly acute MR, will lead to increased left atrial pressure, pulmonary pressure, congestion, edema, and hypoxemia. In the same spot, it contributes to a significant drop in cardiac output, which might lead to hypoperfusion and CS. Prompt assessment is required, particularly if the patient is unstable, to plan and decide about possible life-saving interventions.
Patients with MR should receive guideline-directed management and therapy. However, those with primary MR due to papillary or chordal rupture as a consequence of myocardial infarction might develop persistent heart failure symptoms and, in a state of cardiogenic, might need intervention, either valve replacement or repair with a general preference of mitral repair as it is minimally invasive less costly and carries lower operative mortality.,
MTEER in acute MR has shown a dramatic improvement in hemodynamics; it decreases the left atrium pressure, increases the cardiac output, and hence, it improves the systemic circulation efficiency. On that basis, mitral valve repair might be effective in CS states secondary to acute MR, and it may rescue patients in refractory CS. Moreover, the limited observational nationwide analysis revealed a signal of reduced in-hospital and 1-year mortality with MTEER compared to those who did not undergo MTEER.
Our patients developed severe MR that burdens their hemodynamics, causing a CS persistently requiring vasopressors and inotropes. After performing MTEER, both patients showed a dramatic hemodynamic response and were able to be weaned off the circulatory supporting medications. The MR improved by two grades, and the patients were discharged shortly after the procedure.
| Conclusion|| |
CS is a life-threatening condition associated with increased in-hospital mortality. MTEER is a potentially promising treatment of ischemic acute severe MR -associated refractory CS. Large prospective international multicenter registries are needed to evaluate the safety and efficacy of MTEER in this setting.
Ethical approval is obtained for this analysis from the institutional review board.
We thank all the Heart Hospital and Cath lab staff for their immense efforts in taking care of our patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]