Impella-Clip: a secure and effective strategy in cardiogenic shock due to acute severe mitral regurgitation. Case resolution

CASE RESOLUTION Given the impossibility to remove the Impella 5.0 device (figure 1) and due to the high surgical risk involved (EuroSCORE II, 48,9%; Society of Thoracic Surgeons score (STS), 16%), percutaneous mitral valve repair was attempted with a MitraClip device (Abbott Laboratories, United States). Figure 1. Normal position of the Impella device as seen on the transesophageal echocardiography. With support from an Impella 5.0 device at a rate of 2 L/min and under transesophageal echocardiography guidance the MitraClip NTW device was implanted at A3-P3 level (greater effective regurgitant orifice area), which resulted in a reduced regurgitant jet (videos 1 and 2 of the supplementary data), improved blood flow into the pulmonary veins, and a transmitral gradient of 4 mmHg. Result was reassessed by reducing hemodynamic support temporarily at 1 L/min. A grade III-IV central regurgitant jet was seen. A second MitraClip NT was implanted at A2-P2 level (videos 3 and 4 of the supplementary data). Difficulties during its positioning due to interference with the Impella 5.0 device were reported, which is why reversal maneuvers towards the atrium were performed. Finally, capture or grasping turned out effective, and the lack of residual mitral regurgitation was confirmed. However, although transmitral gradient increased up to...