Urgent Transcatheter Edge-to-Edge Repair for Severe Mitral Regurgitation with Flail Leaflet in Critically Ill Patients

Introduction Degenerative mitral valve disease (DMR) is a common valvular disorder, and flail leaflet due to ruptured chordae represents an extreme variation of this pathology. Ruptured chordae can present as acute heart failure which requires urgent intervention. Mitral valve surgery is the preferred mode of intervention; however, some patients represent as a significant surgical risk and are often deemed to be inoperable. We aim to characterize patients with ruptured chordae undergoing urgent transcatheter edge-to-edge repair (TEER), and to analyze their clinical and echocardiographic outcomes. Methods At a referral center for several hospitals across Israel, we screened all patients who underwent TEER. We included patients with DMR with flail leaflet due to ruptured chordae, and categorized them into elective and critically ill groups. We evaluated the echocardiographic, hemodynamic and clinical outcomes of these patients. Results The cohort included 49 patients with DMR due to ruptured chordae and flail leaflet, who underwent TEER. Seventeen patients (35%) underwent urgent intervention and 32 patients (65%) underwent an elective procedure. In the urgent group, the average age of the patient was 80.3, with 41.8% being female. Fourteen (82%) received noninvasive ventilation, while three patients (18%) required invasive mechanical ventilation. One patient died due to tamponade, while the other 16 patients all had successful reduction of ≥2 in the MR grade. Left atrial V wave decreased from 41.6 mmHg to 17.9 mmHg (p<0.001), and pulmonic vein flow pattern changed from reversal (68.8%) to a systolic dominant flow in all patients (p=0.001). After the procedure, 78.5% of patients were in New York Heart Association (NYHA) class I or II (p<0.001). There was no significant difference in the overall mortality between the urgent and elective groups, with similar survival rates of 6 months for each group. Conclusion TEER can be safe and feasible with favorable hemodynamic, echocardiographic and clinical outcomes in patients undergoing urgent intervention for flail mitral valve disease. Clinical Perspectives Mitral transcatheter edge-to-edge repair (TEER) is a proven therapy for patients with chronic mitral regurgitation, however data on patients with acute mitral regurgitation limited. This article focuses on acute TEER intervention and provides further information on the safety, feasibility and effectiveness of TEER in critically ill patients due to flail leaflet. The clinical finding supports the role of acute TEER intervention in acutely ill patients with acute mitral regurgitation due to ruptured chordae and flail leaflet.