Abstract
Patients presenting with cardiogenic shock (CS) related to acute, severe mitral regurgitation (MR) are often considered too ill for immediate surgical intervention. Therefore, other less invasive techniques for haemodynamic stabilization should be explored. The purpose of this exploratory study was to investigate the feasibility and outcomes in patients with CS due to severe MR by using a novel approach combining haemodynamic stabilization with left Impella-support plus MR-reduction using MitraClip®. We analysed whether a combined left Impella®/MitraClip®-procedure in a rare population of CS-patients with acute MR requiring mechanical ventilation is a feasible strategy to recovery in patients who had been declined cardiac surgery. Six INTERMACS-1 CS-patients with acute MR were studied at two tertiary cardiac intensive care units. The mean EURO-II score was 39 ± 19% and age 66.8 ± 4.9 years. All patients had an initial pulmonary capillary wedge pressure >20 mmHg and pulmonary oedema necessitating invasive ventilation. Cardiac output was severely impaired (left ventricular outflow tract velocity time index 9.8 ± 1.8 cm), requiring mechanical circulatory support (MCS) (Impella®-CP; mean flow 2.9 ± 1.8 L per minute; mean support 9.7 ± 6.0 days). Despite MCS-guided unloading, weaning from ventilation failed due to persisting pulmonary oedema necessitating MR-reduction. In all cases, the severe MR was reduced to mild using percutaneous MitraClip®-procedure, followed by successful weaning from invasive ventilation. Survival to discharge was 86%, with all surviving and rare readmission for heart failure at 6 months. A combined Impella®/MitraClip®-strategy appears a novel, feasible alternative for weaning CS-patients presenting with acute, severe MR. Upfront Impella®-stabilization facilitates safe bridging to Mitraclip®-procedure and the staged approach facilitates successful weaning from ventilatory support.
Highlights
Acute, severe mitral regurgitation (MR) occurs as a result of an abrupt failure of the mitral valve apparatus, such as rupture of a papillary muscle or chordae, resulting in flail mitral leaflets.[1]
A combined ImpellaVR /MitraClipVR -strategy appears a novel, feasible alternative for weaning cardiogenic shock (CS)-patients presenting with acute, severe MR
Upfront ImpellaVR -stabilization facilitates safe bridging to MitraclipVR -procedure and the staged approach facilitates successful weaning from ventilatory support
Summary
Severe mitral regurgitation (MR) occurs as a result of an abrupt failure of the mitral valve apparatus, such as rupture of a papillary muscle or chordae, resulting in flail mitral leaflets.[1]. Patients develop severe decompensated heart failure due to an acute reduction in cardiac output, caused by a major proportion of the blood pumped by the left ventricle retrogradely into the left atrium instead of flowing forward through the aortic valve (Figure 1A, left panel; forward failure). This leads to an acute cardiac pressure and volume overload and pulmonary oedema and hypoxia ensues. Acute severe MR is traditionally treated surgically, but significant intra- and postoperative risks exist, in particular where CS and pulmonary oedema are present. Conventional management of CS includes using intravenous fluids and vasoactive agents; these may result in greater MR and worsening pulmonary oedema with only minimal improvement in forward flow, and/or exacerbation of hypotension.[2,3] Even if stabilization using these methods is achieved, the risks from open surgical intervention remain, even if minimally invasive techniques are utilized
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