2024 Volume 88 Issue 9 Pages 1499-
An 84-year-old woman suffered acute myocardial infarction (AMI) and decompensated heart failure (DHF) due to stent thrombosis after spinal surgery. Echocardiography showed decreased ejection fraction of 35% and severe mitral regurgitation (MR). First, primary coronary intervention was performed for in-stent subocclusion at left anterior descending artery, but atrial fibrillation (AF) and DHF with cardiogenic shock developed, and inotropic drugs were ineffective. The severe MR (3-dimensional echocardiographic vena contracta area: 0.53 cm2) due to tethering of the anterior leaflets was diagnosed as the cause of DHF (Figure A,B). Although intra-aortic balloon pumping (IABP) was considered, withdrawal would be difficult, and because she was elderly and frail there was concern over a deleterious effect on her activities of daily life after a prolonged hospitalization.
TTE and TEE images before and after TEER, and intraoperative monitors and ECG. (A) TTE images before TEER. (B) TEE images before TEER. (C) TEE image during clip gripper-down. (D) TEE images after TEER. (E) TTE images after TEER. (F) Intraoperative pulse monitors. (G) Intraoperative ECG. bpm, beats/min; ECG, electrocardiogram; HR, heart rate; LA, left atrium; LV, left ventricle; TEE, transesophageal echocardiography; TEER, transcatheter edge to edge mitral valve repair; TTE, transthoracic echocardiography.
Therefore, the Heart Team decided to perform emergency transcatheter edge-to-edge mitral valve repair (TEER). Immediately after gripper-down of a NTW-Mitraclip (Abbott, Abbott Park, IL, USA) on the A2-P2 lesion (Figure C), rapid AF recovered to sinus rhythm, and finally the MR grade improved to mild (Figure D–G). The cardiac output index increased from 1.5 to 2.3L/m2, and the mean left atrial pressure decreased from 40 to 20 mmHg. After TEER, her mean blood pressure increased from 50 to 70 mmHg and diuresis was obtained. Intravenous inotropic drugs were quickly tapered off, and the DHF improved.
Patients with severe ischemic MR due to AMI require mechanical support such as IABP, which can reduce the left ventricular afterload and reduce MR. However, the weaning of IABP can lead to recurrence of MR. TEER, on the other hand, is effective for severe MR in patients with high surgical risk.1 Thus, because it is important to sufficiently reduce MR in the acute phase, emergency TEER is a treatment option, especially in elderly patients.
K.M. and G.N. receive lecture fees from Abbott. All other authors have no conflicts of interest to declare.
