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MitraClip for Papillary Muscle Rupture in Patient With Cardiogenic Shock
Canadian Journal of Cardiology 30 (2014) 1461.e13e1461.e14 www.onlinecjc.ca
Case Report
MitraClip for Papillary Muscle Rupture in Patient With Cardiogenic Shock Rafael Wolff, MD, Gideon Cohen, MD, PhD, Carly Peterson, MD, Sophia Wong, MD, Edgar Hockman, MD, Jonathan Lo, MD, Bradley H. Strauss, MD, PhD, and Eric A. Cohen, MD Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
ABSTRACT
RESUM E
We report the successful use of the MitraClip device (Abbott Vascular, Santa Clara, CA) in a 68-year-old man with posterolateral ST-elevation myocardial infarction complicated by papillary muscle rupture and cardiogenic shock.
sentons un cas d’utilisation re ussie du dispositif MitraClip Nous pre (Abbott Vascular, Santa Clara, CA) chez un homme de 68 ans ayant rolate ral avec sus-de calage du subi un infarctus du myocarde poste de la rupture du muscle papillaire et d’un choc segment ST complique nique. cardioge
Acute mitral regurgitation (MR) secondary to papillary muscle rupture (PMR) occurs in 1%-5% of cases of myocardial infarction and is present in 7% of patients in cardiogenic shock.1 Without emergent surgical intervention, acute PMR yields mortality rates as high as 80% within the first 24 hours, with survival rates of only 6% at 2 months.1 Percutaneous edge-to-edge mitral valve repair using the MitraClip device (Abbott Vascular, Santa Clara, CA) has evolved as a promising tool for the management of chronic severe MR.2 We report the successful application of the MitraClip device for acute severe MR and cardiogenic shock secondary to postinfarction PMR.
and inotropic support was initiated. Coronary angiography showed occlusion of the large first obtuse marginal artery (Fig. 1). Left ventricular (LV) angiography demonstrated poor , view video oncontractility with severe MR (Video 1 line). Right heart catheterization demonstrated a mean pulmonary capillary wedge pressure of 37 mm Hg with prominent V waves (55 mm Hg). Transesophageal echocardiography revealed significant LV dysfunction (ejection fraction [EF] w 25%), mild to moderate right ventricular dysfunction with severe posteriorly directed MR secondary to rupture of the anterolateral papillary muscle and flail of the A2 , view video online). The pasegment (Videos 2 and 3 tient’s condition deteriorated with oliguric acute renal failure and multiple episodes of ventricular tachycardia/fibrillation. Because of the patient’s extremely high surgical risk (Society of Thoracic Surgeons score, 64%; euroSCORE II, 75%), a decision was made to attempt percutaneous repair with the MitraClip device. The procedure was performed 24 hours after admission. Two MitraClip devices were deployed at the central A2-P2 interface. Transesophageal echocardiography demonstrated a significant reduction in MR grade from 4þ to 2þ (Video 4 , view video online) accompanied by a reduction in Vwave amplitude from 55 to 30 mm Hg. The patient was extubated and weaned from inotropic and intra-aortic balloon pump support on postoperative day 2 and was discharged 14 days after presentation. Transthoracic echocardiography at discharge demonstrated a LVEF of 30% and LV end-diastolic diameter/LV end-systolic diameter of 5.1/4.6 cm with normal right ventricular function and 1-2þ MR. At the 3-month follow-up, the patient was in New York Heart Association class II. Echocardiography showed LV remodelling (LV enddiastolic diameter/LV end-systolic diameter, 6.2/5.0 cm)
Case Presentation A 68-year-old man presented with a 3-day history of increasing retrosternal chest discomfort and shortness of breath. The patient was diaphoretic, tachycardic, and hypotensive (76/42 mm Hg) and deteriorated rapidly, with resultant pulmonary edema and cardiogenic shock requiring intubation. A short but loud apical systolic murmur was present. Electrocardiography demonstrated sinus tachycardia with ST elevations and Q waves present in the lateral and posterior leads. The patient was transferred emergently to the catheterization laboratory. An intra-aortic balloon pump was inserted, Received for publication May 10, 2014. Accepted July 1, 2014. Corresponding author: Dr Rafael Wolff, Division of Cardiology, Sunnybrook Health Science Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. Tel.: þ1-416-480-5880. E-mail: [email protected] See page 1461.e14 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.07.015 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1461.e14
Canadian Journal of Cardiology Volume 30 2014
preserved LV function (EF, 45%) and more stable hemodynamics, which allowed the MitraClip procedure to be performed 7 days after admission as an urgent but not emergent procedure. A recent study has reported the feasibility and efficacy of the MitraClip procedure in 6 critically ill patients with severe MR.5 Four of these patients presented with acute myocardial infarction and papillary muscle dysfunction but without PMR. In our case, the initial intention was to stabilize the patient in preparation for eventual surgical repair. However, the patient responded extremely well and to this point has not required further intervention. This case highlights the potential utility of percutaneous edge-to-edge repair of acute severe MR in extremely high-risk patients. Disclosures E.A.C. and G.C. have received consulting fees and speaking honoraria from Abbott Vascular. References Figure 1. Coronary angiography demonstrated occlusion of large first obtuse marginal artery.
with overall improvement in LV function (EF, 38%) and 1, view video online). At the 6-month 2þ MR (Video 5 follow-up, the patient remained in New York Heart Association class II. Discussion Acute severe MR caused by PMR is a rare but serious complication of acute myocardial infarction. Immediate surgical intervention carries very high risks in patients already compromised by cardiogenic shock and LV dysfunction.1,3 Mitral valve replacement is preferred in unstable patients, but valve repair, when feasible, may offer improved surgical outcome.3 Our patient was extremely unstable, with a very high predicted operative risk. The successful deployment of the MitraClip substantially reduced the degree of MR, allowing initial stabilization, and clearly altered at least the short-term outcome. A similar case was published recently4; however, in that report the described patient had relatively
1. Kishon Y, Oh JK, Schaff HV, et al. Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients. Mayo Clin Proc 1992;67:1023-30. 2. Feldman T, Foster E, Glower DD, et al. EVEREST II Investigators. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364:1395-406. 3. Fasol R, Lakew F, Wetter S. Mitral repair in patients with a ruptured papillary muscle. Am Heart J 2000;139:549-54. 4. Bilge M, Alemdar R, Yasar AS. Successful percutaneous mitral valve repair with the MitraClip system of acute mitral regurgitation due to papillary muscle rupture as complication of acute myocardial infarction. Catheter Cardiovasc Interv 2014;83:E137-40. 5. Pleger ST, Chorianopoulos E, Krumsdorf U, Katus HA, Bekeredjian R. Percutaneous edge-to-edge repair of mitral regurgitation as a bail-out strategy in critically ill patients. J Invasive Cardiol 2013;25:69-72.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.07.015.
Case Report
MitraClip for Papillary Muscle Rupture in Patient With Cardiogenic Shock Rafael Wolff, MD, Gideon Cohen, MD, PhD, Carly Peterson, MD, Sophia Wong, MD, Edgar Hockman, MD, Jonathan Lo, MD, Bradley H. Strauss, MD, PhD, and Eric A. Cohen, MD Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
ABSTRACT
RESUM E
We report the successful use of the MitraClip device (Abbott Vascular, Santa Clara, CA) in a 68-year-old man with posterolateral ST-elevation myocardial infarction complicated by papillary muscle rupture and cardiogenic shock.
sentons un cas d’utilisation re ussie du dispositif MitraClip Nous pre (Abbott Vascular, Santa Clara, CA) chez un homme de 68 ans ayant rolate ral avec sus-de calage du subi un infarctus du myocarde poste de la rupture du muscle papillaire et d’un choc segment ST complique nique. cardioge
Acute mitral regurgitation (MR) secondary to papillary muscle rupture (PMR) occurs in 1%-5% of cases of myocardial infarction and is present in 7% of patients in cardiogenic shock.1 Without emergent surgical intervention, acute PMR yields mortality rates as high as 80% within the first 24 hours, with survival rates of only 6% at 2 months.1 Percutaneous edge-to-edge mitral valve repair using the MitraClip device (Abbott Vascular, Santa Clara, CA) has evolved as a promising tool for the management of chronic severe MR.2 We report the successful application of the MitraClip device for acute severe MR and cardiogenic shock secondary to postinfarction PMR.
and inotropic support was initiated. Coronary angiography showed occlusion of the large first obtuse marginal artery (Fig. 1). Left ventricular (LV) angiography demonstrated poor , view video oncontractility with severe MR (Video 1 line). Right heart catheterization demonstrated a mean pulmonary capillary wedge pressure of 37 mm Hg with prominent V waves (55 mm Hg). Transesophageal echocardiography revealed significant LV dysfunction (ejection fraction [EF] w 25%), mild to moderate right ventricular dysfunction with severe posteriorly directed MR secondary to rupture of the anterolateral papillary muscle and flail of the A2 , view video online). The pasegment (Videos 2 and 3 tient’s condition deteriorated with oliguric acute renal failure and multiple episodes of ventricular tachycardia/fibrillation. Because of the patient’s extremely high surgical risk (Society of Thoracic Surgeons score, 64%; euroSCORE II, 75%), a decision was made to attempt percutaneous repair with the MitraClip device. The procedure was performed 24 hours after admission. Two MitraClip devices were deployed at the central A2-P2 interface. Transesophageal echocardiography demonstrated a significant reduction in MR grade from 4þ to 2þ (Video 4 , view video online) accompanied by a reduction in Vwave amplitude from 55 to 30 mm Hg. The patient was extubated and weaned from inotropic and intra-aortic balloon pump support on postoperative day 2 and was discharged 14 days after presentation. Transthoracic echocardiography at discharge demonstrated a LVEF of 30% and LV end-diastolic diameter/LV end-systolic diameter of 5.1/4.6 cm with normal right ventricular function and 1-2þ MR. At the 3-month follow-up, the patient was in New York Heart Association class II. Echocardiography showed LV remodelling (LV enddiastolic diameter/LV end-systolic diameter, 6.2/5.0 cm)
Case Presentation A 68-year-old man presented with a 3-day history of increasing retrosternal chest discomfort and shortness of breath. The patient was diaphoretic, tachycardic, and hypotensive (76/42 mm Hg) and deteriorated rapidly, with resultant pulmonary edema and cardiogenic shock requiring intubation. A short but loud apical systolic murmur was present. Electrocardiography demonstrated sinus tachycardia with ST elevations and Q waves present in the lateral and posterior leads. The patient was transferred emergently to the catheterization laboratory. An intra-aortic balloon pump was inserted, Received for publication May 10, 2014. Accepted July 1, 2014. Corresponding author: Dr Rafael Wolff, Division of Cardiology, Sunnybrook Health Science Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. Tel.: þ1-416-480-5880. E-mail: [email protected] See page 1461.e14 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.07.015 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1461.e14
Canadian Journal of Cardiology Volume 30 2014
preserved LV function (EF, 45%) and more stable hemodynamics, which allowed the MitraClip procedure to be performed 7 days after admission as an urgent but not emergent procedure. A recent study has reported the feasibility and efficacy of the MitraClip procedure in 6 critically ill patients with severe MR.5 Four of these patients presented with acute myocardial infarction and papillary muscle dysfunction but without PMR. In our case, the initial intention was to stabilize the patient in preparation for eventual surgical repair. However, the patient responded extremely well and to this point has not required further intervention. This case highlights the potential utility of percutaneous edge-to-edge repair of acute severe MR in extremely high-risk patients. Disclosures E.A.C. and G.C. have received consulting fees and speaking honoraria from Abbott Vascular. References Figure 1. Coronary angiography demonstrated occlusion of large first obtuse marginal artery.
with overall improvement in LV function (EF, 38%) and 1, view video online). At the 6-month 2þ MR (Video 5 follow-up, the patient remained in New York Heart Association class II. Discussion Acute severe MR caused by PMR is a rare but serious complication of acute myocardial infarction. Immediate surgical intervention carries very high risks in patients already compromised by cardiogenic shock and LV dysfunction.1,3 Mitral valve replacement is preferred in unstable patients, but valve repair, when feasible, may offer improved surgical outcome.3 Our patient was extremely unstable, with a very high predicted operative risk. The successful deployment of the MitraClip substantially reduced the degree of MR, allowing initial stabilization, and clearly altered at least the short-term outcome. A similar case was published recently4; however, in that report the described patient had relatively
1. Kishon Y, Oh JK, Schaff HV, et al. Mitral valve operation in postinfarction rupture of a papillary muscle: immediate results and long-term follow-up of 22 patients. Mayo Clin Proc 1992;67:1023-30. 2. Feldman T, Foster E, Glower DD, et al. EVEREST II Investigators. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364:1395-406. 3. Fasol R, Lakew F, Wetter S. Mitral repair in patients with a ruptured papillary muscle. Am Heart J 2000;139:549-54. 4. Bilge M, Alemdar R, Yasar AS. Successful percutaneous mitral valve repair with the MitraClip system of acute mitral regurgitation due to papillary muscle rupture as complication of acute myocardial infarction. Catheter Cardiovasc Interv 2014;83:E137-40. 5. Pleger ST, Chorianopoulos E, Krumsdorf U, Katus HA, Bekeredjian R. Percutaneous edge-to-edge repair of mitral regurgitation as a bail-out strategy in critically ill patients. J Invasive Cardiol 2013;25:69-72.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.07.015.