Abstract 12900: To Rescue or Not to Rescue? Multiple MitraClips for Ruptured Chordae on VA-ECMO

Background:Role of MitraClip as rescue therapy in patients with severe mitral regurgitation (MR) in the setting of ruptured chordae with profound cardiogenic shock in hypertrophic obstructive cardiomyopathy (HOCM) is not well known.Case:60-year-old male presented with profound cardiogenic shock requiring ECMO with severe lactic acidosis. Past medical history included HOCM s/p septal ablation and ICD, mild MR, a-fib s/p watchman, and CKD stage 3.Transesophageal echocardiogram demonstrated a flail posterior mitral valve leaflet due to ruptured chordae tendineae with anteriorly directed jet of severe MR (figure 1A). VA-ECMO was initiated for profound hypotension. 3 MitraClips were required as rescue strategy as the patient was deemed too critical to undergo surgical repair. Post procedure, MR was mild with a mean MV gradient of 4 mmHg at the end of the procedure (figure 1B). 15 months post-hospitalization, patient reported dyspnea on exertion. Exercise stress echo revealed a mean MV resting gradient of 7 mmHg that increased to 16 mmHg at 50 W exercise (figure 1C). Invasive hemodynamics showed a mean gradient of 12 mmHg between LV end-diastolic pressure and pulmonary capillary wedge pressure (figure 1D) confirming severe mitral stenosis. The patient is currently being evaluated for surgical MV replacement.Discussion:Transcatheter edge-to-edge mitral valve repair (TMVr) has been studied extensively in patients with dilated cardiomyopathy, and chronic stable severe MR. There is limited data to show that TMVr can be used as salvage therapy in patients with acute torrential MR with underlying HOCM while being supported with ECMO. However, long-term sequelae needs meticulous follow up and prospective studies to establish short and long-term outcomes and safety. This case highlights potential role of TMVr in acute MR settings in the extreme case of profound cardiogenic shock requiring VA-ECMO leading to candidacy for mitral valve replacement in ambulatory setting.