Percutaneous mitral valve repair with MitraClip XTR for acute mitral regurgitation due to papillary muscle rupture

Abstract

Papillary muscle rupture is an infrequent and highly morbid mechanical complication of acute myocardial infarction. Surgical repair or replacement is traditionally considered first-line therapy. However, many of these patients present in extremis with prohibitively high surgical risk. Repair of mitral regurgitation with the MitraClip device (Abbot Vascular, Menlo Park, CA, USA) is an established therapy to treat degenerative and functional mitral regurgitation. We present a case of successful repair of severe mitral regurgitation due to papillary muscle rupture in the setting of acute myocardial infarction. A two-clip strategy resulted in mild residual mitral regurgitation with resolution of cardiogenic shock and refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation. Six-month follow-up echocardiogram identified durable results with mild mitral regurgitation and left ventricular ejection fraction of 63 %. Our case demonstrates that percutaneous mitral valve repair with MitraClip is a well-tolerated procedure that can provide acute and long-term benefit for patients with acute mitral regurgitation due to papillary muscle rupture who are at prohibitively high surgical risk. <Learning Objective: Our case illustrates the role of MitraClip in acute mitral regurgitation due to papillary muscle rupture in cardiogenic shock as an alternative to surgical intervention in extremely high-risk patients.>.

Keywords: Cardiogenic shock; Intervention; Mitral valve disease; Myocardial infarction; Percutaneous; Structural heart disease.

Fig. 1

(A) Long-axis view identifying the ruptured anterolateral (AL) papillary muscle head. (B) 3-D reconstruction demonstrating ruptured AL papillary muscle and associated posterior leaflet (P2) flail. (C) Mid-esophageal view showing severe mitral regurgitation and Impella CP placed across the aortic valve. (D) Orienting the first MitraClip over the A2-P2 segment of the mitral valve. (E) Orienting the second MitraClip along the A2-P2 segment of the mitral valve, lateral to the previously placed first MitraClip. (F) Continuous wave Doppler through the mitral valve following MitraClip × 2 placement with a mean gradient of 6 mmHg.