Substantial challenge for a patient with severe mitral regurgitation and pulmonary hypertension undergoing transcatheter mitral valve edge-to-edge repair procedure

The transcatheter mitral valve edge-to-edge repair (TEER) procedure is a percutaneous transcatheter intervention for severe mitral regurgitation in patients deemed to have significant comorbidities. It is considered a minimally invasive procedure. However, pulmonary hypertension as a common concomitant pathology with mitral regurgitation makes anesthetic management of the procedure challenging and may lead to unexpected perioperative adverse events. We present a case highlighting 2 distinctive intraoperative events of a patient with severe mitral regurgitation and pulmonary hypertension undergoing the TEER procedure: (1) rapid and profound cardiogenic shock after apnea episode and (2) significant right-to-left shunt of iatrogenic residual atrial septal defect after clip deployment, where pulmonary hypertension played a pivotal role in both events. An in-depth understanding of the pathophysiology of mitral regurgitation and the TEER procedure sets the foundation for risk assessment and anesthesia planning. Moreover, application of transesophageal echocardiography is essential in resuscitation optimization and surgical decision making.