The worst MitraClip Scenario: acute mitral regurgitation due to papillary muscle rupture

Abstract

An 81-year-old woman with a past medical history of coronary artery bypass grafting presented in the emergency department with increasing dyspnea and chest pain over the last two days. The electrocardiogram (ECG) showed ST segment elevation in the inferior leads, coupled with a high level of high-sensitivity cardiac troponin I. The patient was diagnosed with ST-segment elevation myocardial infarction. Coronary angiography was performed and showed an acute thrombosis of the right coronary artery in the middle portion, which was treated with percutaneous thrombo-aspiration and placement of two drug-eluting stents. Due to hemodynamic and respiratory deterioration, the patient was intubated, transferred to the intensive care unit (ICU) and an intra-aortic balloon pump (IABP) placed through the right femoral artery. Despite support with IABP and high doses of inotropes, the patient‘s hemodynamic situation further deteriorated. A transthoracic echocardiogram showed torrential mitral regurgitation (MR) due to a complete rupture of the postero-medial papillary muscle (PMR). The patient was deemed to have prohibitive surgical risk [estimated mortality: EuroSCORE II 71.02%; Society of Thoracic Surgeons (STS) score 70.77%] and after a multidisciplinary heart team discussion, an emergency MitraClip XTR (Abbott Structural Heart, Santa Clara, California, USA) was successfully performed. This case clearly shows that the MitraClip can be used as a good alternative in high-risk patients presenting with acute MR due to PMR