CASE PRESENTATION

This is the case of a 61-year-old man with cardiovascular risk factors who presents with a 3-day history of intermittent oppressive pain in the middle of his chest. The electrocardiogram confirmed the presence of an inferior-posterior wall ST-segment elevation. The emergency coronary angiography revealed the acute occlusion of a dominant left circumflex artery (videos 1 and 2 of the supplementary data) that was revascularized with 2 drug-eluting stents in the proximal left circumflex artery (bifurcation with the first obtuse marginal artery) using the TAP technique (T and small protrusion) (figure 1 and video 3 of the supplementary data). No other significant epicardial lesions were found. During the procedure the patient became desaturated, developed progressive hypotension, and eventually required invasive mechanical ventilation and intra-aortic balloon pump implantation. The echocardiogram confirmed the presence of significant mitral regurgitation (MR) with a slightly depressed left ventricular ejection fraction (LVEF) and inferior-lateral and apical akinesis with preserved right ventricular function. The transesophageal echocardiography confirmed the diagnosis of acute mitral regurgitation of ischemic etiology with a predominant jet at medial level, and no organ damage to the valve or the subvalvular apparatus (figure 2 and video 4 of the supplementary data). Within the next few hours, the patient developed refractory hypotension to vasoactive drugs and multi-organ failure. In the successive electrocardiograms performed the inferior wall ST-segment elevation was maintained. After studying disease progression, the intra-aortic balloon pump was exchanged for an Impella CP device (Abiomed; United States) via right femoral artery. A different coronary angiography was performed through the Impella introducer-sheath (figure 3) that discarded the presence of stent thrombosis (figure 4). Within the next few days, mechanical support was maintained with the Impella CP device at a rate of 2.5 L/min, and negative fluid balances were forced through continuous veno-venous hemodiafiltration that allowed extubation 72 hours later. Severe mitral regurgitation with a slightly improved LVEF still persisted on the control echocardiography, which stopped the removal of the Impella CP device. Also, the patient developed hemolysis with significant anemia (Hemoglobin levels of 7.8 g/dL) and thrombocytopenia, and required transfusion support. No significant bleeding event was reported. Since it was necessary to remove the device and LVEF had recently improved with a perspective of recovery of acute valvular heart disease, the implantation of an Impella 5.0 device was decided via right subclavian access. Ten days after days the acute event, do you think of a way to move on with treatment?


Figure 1. Revascularization using the TAP technique (T and small protrusion). LCx, left circumflex artery; OM1, first obtuse marginal artery.



Figure 2. Transesophageal echocardiography showing severe central mitral regurgitation in A3-P3 with another jet in A2-P2.



Figure 3. Only access via right femoral artery.



Figure 4. Impella CP device with previous patent stents. LAD, left anterior descending coronary artery; LCx, left circumflex artery; OM1, first obtuse marginal artery.


The case was published after obtaining the patient’s verbal consent.

FUNDING

None whatsoever.

AUTHORS’ CONTRIBUTIONS

All the authors contributed drafting or reviewing the case.

CONFLICTS OF INTEREST

R. Moreno is associate editor of REC: Interventional Cardiology; the journal’s editorial procedure to ensure the impartial handling of the manuscript has been followed. A. Jurado-Román is a member of the editorial team. The remaining authors declared no conflicts of interest whatsoever.

SUPPLEMENTARY DATA



Vídeo 1. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000317



Vídeo 2. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000317



Vídeo 3. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000317



Vídeo 4. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000317

* Corresponding author.

E-mail address: claraugueto@gmail.com (C. Ugueto-Rodrigo).

  @Hemodin_LaPaz

HOW WOULD I APPROACH IT?

In their case presentation, authors described an interesting case of acute severe mitral regurgitation of functional etiology due to inferior wall myocardial infarction progressing into cardiogenic shock.

Acute and subacute mitral regurgitation due to myocardial infarction is a clinical condition of grim prognosis that is relatively common in our routine clinical practice.1

These patients’ sign of presentation can be rapidly progressive heart failure hours or days after the ischemic event with poor response to medical therapy. No wonder then that, on many occasions,2,3 in the evolved infarction without reperfusion or delayed reperfusion setting, severe rapidly progressive courses towards cardiogenic shock can occur.

The fundamental anatomical mechanism through which mitral regurgitation occurs can be posterior leaflet restriction often in its more medial or medial-central scallops (P3 or P2-P3) due to specific regional dysfunction of myocardial contractility due to infarction.1

As in the case presented here, these are often inferior or inferior-posterior wall myocardial infarctions due to the occlusions of very-well developed left circumflex arteries or very dominant right coronary arteries. These are high-surgical risk patients following their poor clinical and hemodynamic situation. Although, traditionally, the only possible procedure for these patients was mitral valve repair or replacement surgery, surgical results are associated with a high in-hospital mortality rate due to both these patients’ unstable clinical situation and procedural complications.1

In this sense, transcatheter mitral valve repair with edge-to-edge approximation has proven as a safe and effective option even in the presence of cardiogenic shock.1-3

In this clinical setting, the first thing that should be taken into consideration is the patient’s hemodynamic support with the device each center is most experienced at. Afterwards, transcatheter mitral valve repair can be considered to treat valvular heart disease as a first-line therapy in cases of favorable anatomy as it is a fast and effective solution with a low rate of complications and lower mortality rates reported compared to surgical and, obviously, conservative treatment.1

In a case like the one presented by the authors, the first I would do is to guarantee the patient’s hemodynamic support. In this sense, devices like the Impella CP (Abiomed, United States) or a combination of extracorporeal membrane oxygenation and intra-aortic balloon pump could be good alternatives.

The next step would be to perform transcatheter mitral valve repair with the MitraClip device (Abbott vascular, United States). I would use the right femoral venous access with ultrasound-guided puncture and perform a transesophageal echocardiography-guided transseptal puncture (posterior and superior). The technical characteristics of the procedure in an acute setting are no different compared to those of a scheduled case. Due to the medial-central origin, width of the device, and length of the leaflet, in that area my strategy would be to use a MitraClip NTW device (small and wide) for the most commissural region (A3-P3) probably followed by a second similar MitraClip device (NTW) attached to the former towards the valve medial-central region.

In cases where the posterior leaflet has a larger size and there is a possibility of associated anterior leaflet pseudoprolapse, the use of a larger clip (XT or XTW) or a capture maneuver regardless of the leaflets would be necessary to facilitate device implantation and improve valve coaptation.

We should be extra cautious with patients like the one presented here due to the possibility of an unusual interference between the MitraClip release catheter and the Impella catheter when crossing the mitral valve to capture the leaflets.

It is of paramount importance to reduce hemodynamic support momentarily (in this case the blood flow supplied by the Impella device) to assess the transmitral gradient, the degree of residual mitral regurgitation after the first clip, and the final outcomes.

The case presented here is that of a particularly significant clinical condition due to its severity, emergency, and high-surgical risk.

Transcatheter mitral valve repair with edge-to-edge approximation can be considered a first-line therapy not only because it is not too aggressive, and also because it is safe, fast, and effective in patients with severe, acute, functional mitral regurgitation with heart failure due to myocardial infarction causing mitral posterior leaflet restriction.1

FUNDING

None whatsoever.

CONFLICTS OF INTEREST

I. Pascual is a proctor of MitraClip for Abbott Vascular.

REFERENCES

1. Haberman D, Estévez-Loureiro R, Benito-Gonzalez T, et al. Conservative, surgical, and percutaneous treatment for mitral regurgitation shortly after acute myocardial infarction. Eur Heart J. 2022;43:641-650.

2. Jung RG, Simard T, Kovach C, et al. Transcatheter Mitral Valve Repair in Cardiogenic Shock and Mitral Regurgitation: A Patient-Level, Multicenter Analysis. JACC Cardiovasc Interv. 2021;11:1-11.

3. Tang GHL, Estevez-Loureiro R, Yu Y, et al. Survival Following Edge-to-Edge Transcatheter Mitral Valve Repair in Patients With Cardiogenic Shock: A Nationwide Analysis. J Am Heart Assoc. 2021;20:e019882.

* Corresponding author.

E-mail address: ipascua@live.com (I. Pascual).

CASE RESOLUTION

Given the impossibility to remove the Impella 5.0 device (figure 1) and due to the high surgical risk involved (EuroSCORE II, 48,9%; Society of Thoracic Surgeons score (STS), 16%), percutaneous mitral valve repair was attempted with a MitraClip device (Abbott Laboratories, United States).


Figure 1. Normal position of the Impella device as seen on the transesophageal echocardiography.


With support from an Impella 5.0 device at a rate of 2 L/min and under transesophageal echocardiography guidance the MitraClip NTW device was implanted at A3-P3 level (greater effective regurgitant orifice area), which resulted in a reduced regurgitant jet (videos 1 and 2 of the supplementary data), improved blood flow into the pulmonary veins, and a transmitral gradient of 4 mmHg. Result was reassessed by reducing hemodynamic support temporarily at 1 L/min. A grade III-IV central regurgitant jet was seen. A second MitraClip NT was implanted at A2-P2 level (videos 3 and 4 of the supplementary data). Difficulties during its positioning due to interference with the Impella 5.0 device were reported, which is why reversal maneuvers towards the atrium were performed. Finally, capture or grasping turned out effective, and the lack of residual mitral regurgitation was confirmed. However, although transmitral gradient increased up to 7 mmHg, after reducing hemodynamic support down to 0.5 L/min, the gradient dropped down to 5 mmHg. Since the presence of hemoglobin levels of 8.6 g/dL and heart rate of 90 bpm could make the gradient could go up slightly—overestimating the measurements—the second device was released with such gradient (figure 2). The patient was extubated and the Impella 5.0 device was removed 72 hours later with satisfactory disease progression.


Figure 2. Final procedural outcomes.


Acute mitral regurgitation is one mechanical complication of infarction that leads to higher mortality rates (35% to 50%)1 because it is associated with cardiogenic shock (CS) with increased retrograde pressure and volume. Circulatory support and vasoactive drugs necessary here. The Impella device actively unloads the left ventricle, increases cardiac output,1 and is indicated in the acute phase.2

Traditional treatment has consisted of emergency heart valve replacement that is associated with significant perioperative mortality. Over the last few years, percutaneous mitral valve repair has proven beneficial in asymptomatic secondary mitral regurgitation despite optimal medical therapy.2 However, data are scarce on acute mitral regurgitation with secondary cardiogenic shock,1,3 which could be particularly beneficial in this setting.

This case describes how a combined strategy of Impella and MitraClip is both safe and effective. However, several technical considerations should be made at this point: a) the MitraClip device should be positioned carefully due to interference with the Impella device; b) hemodynamic support should be reduced to assess results since this support can overestimate the reduction of mitral regurgitation; and c) anemia and tachycardia are not rare, factors that could overestimate the residual gradient.

Long-term follow-up and more evidence are necessary to support this strategy. However, in the ischemic severe acute mitral regurgitation setting complicated with cardiogenic shock, complete percutaneous resolution (coronary revascularization, Impella and percutaneous mitral valve repair) could be the treatment of choice.

The case was published after obtaining the patient’s verbal consent.

FUNDING

None whatsoever.

AUTHORS’ CONTRIBUTIONS

All the authors contributed drafting or reviewing the case.

CONFLICTS OF INTEREST

R. Moreno is associate editor of REC: Interventional Cardiology; the journal’s editorial procedure to ensure the impartial handling of the manuscript has been followed. A. Jurado-Román is a member of the editorial team. The remaining authors declared no conflicts of interest whatsoever.

SUPPLEMENTARY DATA



Vídeo 1. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000319



Vídeo 2. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000319



Vídeo 3. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000319



Vídeo 4. Ugueto-Rodrigo C. DOI: 10.24875/RECICE.M22000319

REFERENCES

1. Vandenbriele C, Balthazar T, Wilson J, et al. Left Impella-device as bridge from cardiogenic shock with acute, severe mitral regurgitation to MitraClip-procedure: a new option for critically ill patients. Eur Heart J Acute Cardiovasc Care. 2021;10:415-421.

2. McDonagh T, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599-3726.

3. Estévez-Loureiro R, Shuvy M, Taramasso M, et al. Use of MitraClip for mitral valve repair in patients with acute mitral regurgitation following acute myocardial infarction: Effect of cardiogenic shock on outcomes (IREMMI Registry). Catheter Cardiovasc Interv. 2021;97:1259-1267.

* Corresponding author.

E-mail address: claraugueto@gmail.com (C. Ugueto-Rodrigo).

  @Hemodin_LaPaz

CASE PRESENTATION

This is the case of an 82-year-old man with a past medical history of permanent atrial fibrillation, chronic obstructive pulmonary disease, and stable Alzheimer’s disease admitted due to heart failure.

Transthoracic echocardiography revealed the presence of bicuspid aortic valve with severe aortic stenosis (maximum gradient, 76 mmHg; mean gradient, 48 mmHg), and a normal left ventricular ejection fraction (60%). During the examination, the coronary angiography documented the presence of proximal and middle right coronary artery severe stenosis treated with dual drug-eluting stent implantation. The baseline cardiac computer tomography angiography showed a bicuspid aortic valve type 1 with a noncoronary right calcified raphe and a 778.5 mm2 area (figure 1).


Figure 1. Computed tomography images. Left: valve measurements. Right: valve reconstruction. LC, left coronary; NC, noncoronary; RC, right coronary; VR, volume rendered.


After Heart Team discussion, transcatheter aortic valve implantation (TAVI) with balloon-expandable was decided. A 29 mm SAPIEN 3 Ultra valve (Edwards Lifesciencies; United States) was scheduled. The patient’s informed consent was obtained. A 16-Fr Edward sheath was inserted via right femoral arterial access, a 7-Fr pigtail catheter was placed into the ascending aorta via left femoral arterial access, and 6-Fr left femoral venous access was used for ventricular pacing lead placement.

All attempts to cross the aortic valve proved ineffective following its severe calcification and complex anatomy despite many different catheters and wires were used by 3 different interventional cardiologists with great experience in TAVI in a center with a volume of 125 procedures each year. Given the numerous unsuccessful attempts made, a bailout solution was needed.

FUNDING

None whatsoever.

AUTHORS’ CONTRIBUTIONS

J. Martínez-Sole, S. Lozano-Edo, and J. Sanz-Sánchez designed, drafted the manuscript, and were involved in the manuscript final approval. F. Ten-Morro, L. Andrés-Lalaguna, and J.L. Díez-Gil designed the study, conducted the manuscript critical review, and approved its final version for publication.

CONFLICTS OF INTEREST

None reported.

* Corresponding author.

E-mail address: sjorge4@gmx.com (J. Sanz Sánchez)

HOW WOULD I APPROACH IT?

The authors present a case of retrogradely uncrossable aortic valve for transcatheter aortic valve implantation (TAVI). This happens with the valve introducer sheath in the femoral artery, and the remaining catheterized accesses. Therefore, a solution to implantation is needed since 1 of the basic steps is missing.

There are 3 situations when crossing a stenosed aortic valve can become especially difficult even for an experienced operator: one is stenosed surgical aortic valves where the ascending aorta is poorly dilated compared to the artificial valve. In this situation, building the latter prevents proper catheter alignment.Another situation is critical aortic stenosis due to small opening orifice. The third situation is bicuspid valves, as it is the case here, with an often dilated ascending aorta or a too vertical valvular plane that complicate maneuvers with the guide catheter. Also, because the bicuspid opening being eccentric often complicates steering the guidewires and the catheters through the valvular orifice.

If we exhaust all retrograde crossing possibilities with different catheters and guidewires, the only option left is antegrade access from the left ventricle (LV) through transseptal catheterization. The use of antegrade access for implantation purposes has already been described in the history of structural heart procedures since it was used for the first TAVI back in 2002.1 Afterwards, it was abandoned due to the high rate of complications and ease of implantation via retrograde transfemoral access. Anyways, some authors still advocate for this access for the lack of better options.2

I would perform the procedure using the right femoral vein since it is easier to perform the transseptal access and shorten the procedure since the retrograde access has already been tried for a while; the left femoral vein—already catheterized—is also valid. Currently, transseptal procedures are performed with much safety through transesophageal echocardiography (TEE) guidance. Once the ultrasound-guided right femoral vein has been punctured, a 0.032 in guidewire is advanced across the superior vena cava through which a sheath is advanced for transseptal puncture, often a 63 cm 8-Fr Schwartz SLO (Abbott Vascular, United States). The guidewire is removed and a Brokenburg BRK-1 XS needle is advanced (Abbott Vascular, United States) up to 0.5 cm of the tip of the SLO catheter. At this point, the TEE is performed. At our center—since all procedures are performed under conscious sedation—we would proceed to increase sedation with a bolus of midazolam and use a TEE microprobe that is better tolerated and provides enough imaging for the puncture or else a conventional TEE probe. We will slide from the superior vena cava until the oval fossa and perform the puncture at halfway. Once in the left atrium we direct the transseptal sheath towards the left superior pulmonary vein leaving the 0.032 in guidewire inside. We remove the transseptal sheath and advance a medium curl deflectable Agilis NxT catheter (Abbott Vascular, United States) mounted on it. Once in the left atrium, dilator and guidewire are removed and deflected to bring the catheter closer to the mitral valve. The right anterior oblique view gives us an idea as to where the mitral valve is. Then, the Agilis is turned towards it. A 4-Fr Glidecath multipurpose hydrophilic diagnostic catheter (Terumo Europe, Belgium) is advanced through it until the apex. It bends while being advanced thanks to the Agilis catheter often pointing to the LV outflow tract. A 260 cm J-shaped tip conventional 0.035 in guidewire is advanced until the valve is crossed. Then it’s advanced through the ascending aorta until the abdominal aorta. If crossing is difficult with the multipurpose catheter, a JR4 catheter or a hydrophilic guidewire can be used. From the right femoral artery and through the TAVI introducer, a 6-Fr JR4 catheter we advance a Gooseneck snare of 20 mm-to-25 mm in diameter. The guidewire is captured and then removed through the artery. Therefore, a venoarterial loop has been created. We’ll remove the guidewire as much as possible through the arterial side. From there, we’ll advance the 6-Fr JR4 guide catheter until the LV and loosen up the tension of the loop so that the catheter can be accommodated towards the LV apex. Then, the guidewire is slowly removed from the venous side while keeping the JR4 inside the LV and the high-support guidewire is advanced from the femoral artery. I would keep the Agilis catheter inside the left atrium until to secure the TAVI guidewire into the LV. From that moment onwards, the procedure follows the transfemoral implantation conventional steps.

FUNDING

None whatsoever.

CONFLICTS OF INTEREST

None reported.

REFERENCES

1. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002;106:3006-3008.

2. Misumida N, Anderson JH, Greason KL, Rihal CS. Antegrade transseptal transcatheter aortic valve replacement: Back to the future? Catheter Cardiovasc Interv. 2020;96:E552-E556.

* Corresponding author.

E-mail address: joseantoniobaz@gmail.com (J.A. Baz Alonso).

  @jabazal

Original articles

Recic 22 074 Uk F3

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Editorials


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Case resolution
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