Percutaneous mitral valve repair using the MitraClip in acute cardiogenic shock

Sirs: Percutaneous mitral valve repair using the MitraClip system (Abbott Vascular) is a rapidly developing therapeutic approach for selected patients suffering from mitral valve regurgitation [1, 2]. Recently, the Endovascular Valve Edge-to-Edge Repair STudy (EVEREST) II has randomly compared catheter-based versus surgical treatment showing promising results for the catheter-based procedure [2]. However, EVEREST II had stringent inclusion criteria, such as left ventricular ejection fraction (LVEF) [25% and left ventricular endsystolic diameter (LVESD) B55 mm and thus may have excluded a substantial number of patients who may benefit from this technology. Recently, Franzen et al. have widened the inclusion criteria and described the feasibility of this procedure in patients at high surgical risk based on the EuroSCORE and patients with severe LV dysfunction [3]. To our knowledge, there exists no published experience in the application of the MitraClip procedure in patients with cardiogenic shock. Here, we present a case of a 51-year-old man with acute cardiogenic shock and multiorgan failure who was referred for implantation of a cardiac-assisted device as bridge to transplantation. The patient suffered from ischemic cardiomyopathy due to two severe anterior wall infarctions in 2008 and 2010 and had undergone ICD implantation in 2010. On admission, the patient presented with progressive cardiogenic shock associated with acute renal failure and beginning liver failure (see Table 1). Transthoracic echocardiography revealed a severely compromised LVEF (15%) and a severe functional mitral regurgitation (MR) grade IV due to left ventricular dilatation (LVESD 58 mm, LVEDD 67 mm). The patient required increasing doses of catecholamines for circulatory support. Initially, dobutamine was started but did not achieve sufficient blood pressure. Adrenaline followed by levosimendane was initiated to increase inotropy in combination with the insertion of an intraaortic balloon pump (IABP) to decrease the afterload. This regimen achieved a transient stabilization. However, the patient could not be continuously weaned from this circulatory support over a period of 10 days requiring repeated intubation and ventilation for lung edema. To further stabilize the patient, we decided to perform a ‘‘rescue’’ MitraClip procedure as a bridge to transplantation procedure. Under the support of the IABP, real-time 3D and 2D-transesophageal echocardiographic and fluoroscopic guidance, the clip was successfully implanted (see Fig. 1) resulting in a reduction of MR grade IV to I–II. Immediately at the end of the procedure, cardiac output improved from 3.0 to 4.3 l min and the blood pressure increased from 100/50 to 124/80 mmHg. Consistently, hemodynamic analysis showed a decrease of the PCWP from 36 to 29 mmHg and a decrease of the PAP from 75/44 to 66/37 mmHg. After 4 h, the patient was extubated and recovered quickly. He was discharged on day 7 after mitral clipping in a clinically stable condition. In the subsequent 3 months, the patient regularly presented in our outpatient clinic for clinical and echocardiographic follow-up [4]. His condition had improved to NYHA functional class II and a consistent MR grade I–II which was associated with improved laboratory parameters (see Table 1). Listing for heart transplantation was withdrawn. C. S. Zuern J. Schreieck H. J. Weig M. Gawaz A. E. May (&) Department of Cardiology, University Hospital of Tubingen, Otfried Muller-Strasse 10, 72076 Tubingen, Germany e-mail: may_andreas@yahoo.de