1. University of Cincinnati Medical Center
Salvage Mitraclip: Successful treatment of cardiogenic shock with percutaneous edge to edge mitral valve repair
Molham Aldeiri, MD
Molham Aldeiri MD, Naseer Khan MD, Haree Vongooru MD, David Harris MD, Imran Arif MD, Satya Shreenivas MD
University of Cincinnati Medical Center

2. Learning objectives
Objective 1: Discuss the management of severe MR and cardiogenic shock – what are the options?
Objective 2: Describe the role of Mitraclip in Cardiogenic Shock.

3. Clinical Presentation
Mr. HP is a 76 year old male with a past medical history significant for ischemic cardiomyopathy and severe mitral regurgitation (MR) who was hospitalized with acute decompensated heart failure.
Past medical history:
Coronary artery bypass graft
Chronic renal insufficiency
COPD
Anemia
Insulin dependent diabetes mellitus

4. TEE
TEE showing severe cardiomyopathy with an LV ejection fraction of 10%

5. TEE
 TEE showing severe (4+) mitral regurgitation

6. Hospital course
Patient was treated with escalating dose of diuretics. However, he continued to deteriorate  and developed cardiogenic shock requiring inotropes, Milrinone mcg/kg/min and Dobutamine 7.5 mcg/kg/min.
Coronary angiogram: showed severe native CAD and patent grafts
RHC: (PA 80/35/50, PCWP 42; Fick CO 3.2; CI 1.7)

7. Hospital course
Cardiac team was consulted and patient options: surgery (STS score of 51), hospice, LVAD, Transcatheter mitral valve repair with MitraClip.
MitraClip is not FDA approved for Functional MR, however as the patient was not a candidate for surgery he was considered for MitraClip.
Cardiac team decision was to perform MitraClip as a salvage mechanism to treat the severe refractory cardiogenic shock.

8. Procedure
Under TEE guidance a position was chosen 4 cm above the mitral annular place and tenting of the septum was visualized and trans-septal puncture was performed.
Utilizing 3D TEE guidance, the clip was positioned co-axial to the valve immediately over the large jet. Post leaftet grasp, the MR severity was reduced to 2-3+ and there was a slight reduction in LA pressure to 8 mmHg. A decision was made to deploy a second clip immediately medial to the previously placed clip. 
Post both mitral clip deployments, the MR severity was reduced from severe (4+) to mild (1+) by color doppler. The left atrial pressure decreased to 4 mmHg. The mitral valve mean gradient was less than 3 mmHg. 

9. Deployment of the second Clip
TEE during procedure
Deployment of the second Clip

10. TEE post MitraClip deployment
Reduction of MR to +1 post second clip deployment

11. Hospital course post MitraClip
Patient was weaned off inotrops same day.
Kidney function improved and urine out put increased.
Patient was ambulatory on post op day 2 and was discharged on post op day 3.
Patient was seen in the clinic 1 month post discharge and was doing good (NYHA II).

12. Take Home Messages
Acute decompensated heart failure in a setting of severe MR is very challenging and hard to treat.
MitraClip may be an effective therapy in the setting of refractory decompensated heart failure with severe functional MR.