Bridge to recovery with a left ventricular assist device and mitral transcatheter edge-to-edge repair in cardiogenic shock due to acute ischemic mitral insufficiency: a novel option to treat patients without surgery or heart transplant?

Cardiogenic shock due to mechanical complications of myocardial infarction (MI) is still associated with a high mortality rate. One of such complications is acute mitral regurgitation (MR), which is treated mainly with a surgical approach.

A 56-year-old man was transferred from a district hospital to the Institute of Heart Diseases (Wroclaw Medical University, Wrocław, Poland) due to cardiogenic shock and acute MR complicating MI. Three days before the admission the patient had undergone percutaneous coronary intervention of the obtuse marginal branch. Chronic total occlusion of the right coronary artery and a borderline lesion of the proximal left anterior descending branch (50% diameter stenosis on angiography) were also found. Transthoracic and transesophageal echocardiography performed on admission revealed severe left ventricular (LV) ejection fraction impairment (30%), and severe MR with posterior leaflet restriction and anterior pseudoprolapse (Figure 1A and 1B). Pulmonary capillary wedge pressure was 20 mm Hg. Intra-aortic balloon pump was implanted ad hoc, and catecholamine support was introduced, but the patient’s condition was not improving. The local shock team decided to escalate mechanical circulatory support to an Impella 5.5 (Abiomed, Danvers, Massachusetts, United States) LV assist device (LVAD), which was implanted the next day through the axillary access with a surgically inserted Dacron graft under visual, transesophageal echocardiography, and fluoroscopy guidance. During the shock team meeting, a heart transplant and surgical mitral repair / replacement were also considered. However, given the patient’s condition, prohibitive surgical risk in his current clinical state, and inability to carry out an immediate heart transplant, a stepwise strategy with LVAD implantation and percutaneous mitral valve repair attempt was chosen. On the following day, a mitral transcatheter edge-to-edge repair (TEER) procedure with a single MitraClip G4 XTW device (Abbott, Santa Clara, California, United States) implantation was performed, which substantially reduced the regurgitation jet (Figure 1C and 1D). LV unloading owing to the support of Impella 5.5 allowed for immediate mitral leaflet grasping, which otherwise would be impossible given the abovementioned MR mechanism. MR reduction led to further stabilization of the patient’s condition, with metabolic and hemodynamic improvement that enabled weaning him off catecholamine support. While on Impella 5.5, a successful angioplasty of the left anterior descending artery was performed (Figure 1E) after confirmation of the lesion severity on intravascular ultrasonography. Final LVAD removal occurred 15 days after its implantation. The patient was discharged home on the 23rd day with LV ejection fraction of 37%, heart failure symptoms in the New York Heart Association functional class II, and mild MR (Figure 1F), on optimal medical treatment.

This is one of few reports describing a combined implantation of MitraClip and Impella 5.5 in an acute setting. Available data based on case studies show that Impella 5.5 offers potent LV support, may be superior to a smaller, percutaneous device (Impella CP), and its use proved effective in patients with severe LV damage.^1-3 Mitral TEER procedure, by default designed to be used in stable, selected patients in whom percutaneous treatment is considered better than surgery, has also been used in an acute setting.⁴ This novel approach has the potential to enable patient recovery from cardiogenic shock due to acute MR complicating MI without heart surgery, preserving the native valve and, in extreme cases, making it possible to omit or postpone a heart transplant.