A Survival Case of Acute Mitral Regurgitation and Cardiogenic Shock Caused by Subtotal Occlusion of the First Diagonal Branch

Abstract Background Acute mitral regurgitation (MR) is an emergency, often requiring urgent surgery. Severe acute MR presenting with hemodynamic collapse is usually caused by papillary muscle rupture or dysfunction after acute myocardial infarction (AMI) or chordal rupture, resulting in flail mitral leaflet(s). Preoperative stabilization is complex due to concomitant hemodynamic collapse and hypoxic respiratory failure. Finding the right balance between both preload and inotropic support is challenging. When patients are too sick for immediate surgical intervention, mechanical circulatory support can be considered because of its ability to both unload and reduce of cardiac work while increasing coronary perfusion and cardiac output. Nevertheless, even after initial stabilization, surgical risk remains high in critically ill acute severe MR patients and transcatheter treatments such as MitraClip are increasingly being explored. Methods Between August 2017 and September 2019, patients presenting with acute severe mitral regurgitation and considered too ill for immediate surgical intervention (EURO-II score >11.2% plus pulmonary oedema necessitating mechanical ventilation and/or hemodynamic instability), were selected for an Impella-assisted LV unloading technique as bridge to MitraClip-procedure. Five patients were selected for the combined left Impella/MitraClip-procedure in two tertiary cardiac ICUs. Results The mean age was 72 years. The cause of MR was ischemic in 20% and all patients presented in cardiogenic shock state, necessitating mechanical ventilation. The overall cardiac operative risk assessment (Euro-II) score predicted a 35% chance of in-hospital mortality. Cardiac output was severely impaired (mean LVOT VTI 8.2 cm). All patients were on inotropic support and supported by an Impella-CP pVAD (mean flow 2.5 Liter per minute; mean 6.3 days of support). In all cases, we managed to reduce the LVEDP below 15 mmHg using the combination of medical therapy (afterload reduction, inotropes), mechanical ventilation and pVAD-therapy. The MR was significantly reduced by a MitraClip-procedure in each Impella supported patient. The overall survival at discharge was 80%. One patient with late referral and multiple organ failure at presentation deceased due to refractory cardiogenic shock. Overall, severe MR was reduced to grade 1+ and all four patients survived 6 months after discharge with only one readmission for decompensated heart failure. Conclusions A combined strategy of Impella and MitraClip appears to be a novel, feasible alternative for patients presenting with acute, severe MR unable to proceed to a corrective surgical procedure at presentation due to severe left ventricular forward flow failure. In these cases, the early initiation of pVAD-support may reduce the risk of development of irreversible end- organ damage and dysfunction. Exploration in a larger, randomised population is warranted to investigate this strategy further. Funding Acknowledgement Type of funding source: None

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Abstract 17230: Acute Flash Pulmonary Edema Leads to a Spot Diagnosis of Acute Mitral Regurgitation From Impella LP 5 Induced Chordae Rupture: A Success Story!!

Circulation ◽

10.1161/circ.138.suppl_1.17230 ◽

2018 ◽

Vol 138 (Suppl_1) ◽

Author(s):

Umama Gorsi ◽

Kenneth Wong ◽

Michail Vitellas

Keyword(s):

Cardiac Arrest ◽

Mitral Regurgitation ◽

Cardiogenic Shock ◽

Pulmonary Edema ◽

Papillary Muscle ◽

Systolic Function ◽

Rare Complication ◽

Drug Eluting Stent ◽

Mechanical Complication ◽

Acute Mitral Regurgitation

Introduction: Impella devices are used as a temporary mechanical support for cardiogenic shock. Acute Mitral Regurgitation is a very rare complication after Impella placement. We present a case of sub-acute mitral regurgitation 2 days after removal of the Impala in a patient with cardiogenic shock after an acute anterior myocardial infarction. Case History: 37-year-old male with no significant past medical history was brought to the Emergency Room because of cardiac arrest at home. Patient had prolonged resuscitation time of about 45 minutes. After return of spontaneous circulation 12-lead electrocardiogram EKG showed typical anterior ST segment elevation MI. Right heart cath confirmed reflecting cardiogenic shock. Coronary angiogram revealed near ostial thrombotic occlusion of the LAD which was successfully treated with a drug-eluting stent. For severely reduced LV systolic function and severe cardiogenic shock Impella CP was inserted. Patient had an episode of cardiac arrest post procedure which was successfully resuscitated. On CCU day one we had a concern about positioning of Impella as it was considered to be under papillary muscle and under fluoroscopy and Echocardiogram guidance we attempted to reposition his Impella. Impella was removed on day 3. However all along we had difficulty adequately oxygenating him. His FiO2 was never below 50%. Eventually 2 days after Impella was removed (day 5 of admission) he had severe flash pulmonary edema. We could not oxygenate him on the ventilator on FiO2 of 100%. There was a concern of acute mitral regurgitation. This was confirmed by transthoracic and transesophageal echocardiogram showed flail anterior mitral leaflet P2 A3 likely chordae rupture. The patient was emergently taken to the operating room by cardiothoracic surgeon to undergo successful mitral valve replacement with a mechanical Saint Jude valve. From there patient slowly recovered. Patient was discharged home directly. Discussion: From the beginning it was felt that patient’s event is secondary to chordae rupture from the Impella device as the patient has otherwise demonstrated very good recovery post revascularization and therefore mechanical complication of MI would not be expected, also provided this was LAD territory along with the fact that the flail leaflet was not mediated by a papillary muscle rupture. Conclusion: It is pertinent to be very careful while repositioning Impella and one should always aim for a fluoroscopic guidance to reposition the device to avoid any damage to the surrounding structure.

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