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CASE20191024_092
| STRUCTURAL HEART DISEASE - Valvular Intervention: Mitral or Tricuspid | |
| A Case of Cardiogenic Shock with Eclipsed Mitral Regurgitation: To Clip or Not to Clip? | |
| Yusuke Kobari1, Kentaro Hayashida1, Keiichi Fukuda1 | |
| Keio University School of Medicine, Japan1, | |
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[Clinical Information]
- Patient initials or identifier number:
S.N.
-Relevant clinical history and physical exam:
The patient was 90-year-old man with atrial fibrillation and mitral regurgitation(MR). He had shortness of breath on exertion in July, 2019. Over the past 1year, he already had been admitted twice for heart failure. Physical examination showed his blood pressure of 76/49 mmHg. Echocardiography showed LV ejection fraction of 50% and severe MR resulting from the wide mal-coaptation of the mitral valve leaflets. With inotropics and respiratory support, his hemodynamic gradually improved.
 preEcho.mov preEcho 2ch.mov-Relevant test results prior to catheterization:
TTE showed preserved EF and the degree of MRdecreased to mild-moderate. However, exercise-stressed TTE revealed that suddenworsening of MR with lowering of blood pressure and severe dyspnea. Fortunately,10 minutes after the end of exercise, severe MR was diminished to mild with improvementof dyspnea. Therefore we diagnosed the patient to have eclipsed MR. Dualscintigraphy showed the ischemia of posterior and lateral wall.
excersice 2ch.mov excersice4ch.mov- Relevant catheterization findings:
Coronary angiography showed no significantstenosis of the both coronary arteries. Acetylcholine provocation test was notperformed. The STS score (for mitral valve replacement) was 3.94%. Consideringthe high age and the risk of surgery of this patient, we have decided to performpercutaneous mitral valve repair (MitraClip).
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[Interventional Management]
- Procedural step:
Under general anesthesia, the first clipwas deployed to A2-P2 medial side. With a single clip, the MR was reduced tomild. The mean mitral gradient was still lower than 3 mmHg. Considering thestability of the clip in case of the exacerbation of MR with the wide jet widthand the wide mal-coaptation of the mitral valve leaflets, we have decided to deploysecond clip to the lateral side of the 1st clip. No complication wasfound. Exercise-stressed TTE revealed that we couldn¡¯t find the exacerbation ofMR and detachment of both clips. The patient was discharged, and until 2 monthsafter the procedure, the patient has not been admitted to our hospital.
post 4ch.mov post3ch.mov postMC_SAX.mov- Case Summary:
We successfully treated the patient with eclipsed MR using percutaneous mitral valve repair. Eclipsed MR is a relatively new concept of MR. Only a few cases have been reported previously, and the etiology is not yet well known. However repeated reoccurrence of heart failure would occur if appropriate treatment is not offered. Previous date showed that optimal medical treatment and surgical mitral valve repair could be effective. In this case, we demonstrated the possible way of controlling eclipsed MR with medication and percutaneous mitral valve repair system. Two or more clips strategy could be reasonable for the exercise-induced MR for the prevention oft he detachment of the clips.
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