A patient-tailored clipping strategy of transcatheter edge-to-edge repair as salvage for cardiogenic shock complicated by mitral valve cleft and bileaflet flails

An 84-year-old male presented to the emergency room with progressive hypotension (blood pressure: 90/52 mmHg) and tachycardia (heart rate: 136 b.p.m.). Examination revealed moist rales over both lungs, irregular heart rhythm, the presence of S3, and a grade 4/6 systolic murmur best heard at the apex. An electrocardiogram showed atrial fibrillation with a fast ventricular response. Bedside transthoracic echocardiography (TTE) demonstrated biatrial dilation, severe mitral regurgitation (MR), and a dilated left ventricular end-diastolic diameter (LVEDD) of 60 mm with an ejection fraction of 62%. A transoesophageal echocardiography revealed significant MR with mitral annulus dilatation, bileaflet flails, and posterior leaflet cleft (Panels A and B). Mitral surgery was deemed high risk. Transcatheter edge-to-edge repair (TEER) was considered as an alternative. The first XTR stabilized haemodynamics by grasping the flailing leaflets, followed by a second NTR placed at the lateral side of the cleft where the leaflet length was sufficient (7.28 mm). In order to maximumly guarantee the physiological mitral valve (MV) coaptation, closing the cleft and reducing device tension on leaflets with pre-existing atriogenic tethering force, the second clip was perpendicular to MV coaptation line and slightly clockwise to the first clip (Panel C). Although there was still mild residual MR due to atrial functional malcoaptation, the blood pressure increased from 90/46 to 110/60 mmHg immediately after the procedure. Follow-up TTE at 12 months showed mild residual MR with an LVEDD of 47 mm. This is the first report to demonstrate that cardiogenic shock complicated by combined bileaflet flails, a cleft, and atrial functional MR can be successfully treated by patient-tailored convergent clipping strategies. Supplementary data are not available at European Heart Journal online. All authors declare no disclosure of interest for this contribution. The data will be shared upon reasonable request.