Transcatheter Edge-to-Edge Repair Under Argatroban in IABP-Supported Acute Mitral Regurgitation With Suspected Heparin-Induced Thrombocytopenia

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a prothrombotic immune-mediated complication that complicates cardiac surgery because cardiopulmonary bypass requires systemic heparinization. We report a case of acute severe mitral regurgitation (MR) complicated by clinically suspected HIT, in which conventional surgical repair was not feasible. CASE SUMMARY: A 59-year-old man presented with acute severe MR due to chordal rupture and developed cardiogenic shock requiring intra-aortic balloon pump support. While awaiting surgery, his platelet count decreased from 262,000/μL to 23,000/μL. The 4Ts score was 6, and PF4/heparin antibody testing was positive, supporting clinically suspected HIT. Because cardiopulmonary bypass requiring systemic heparinization was considered prohibitively high risk, M-TEER was performed under continuous argatroban infusion. Two PASCAL Ace implants were successfully deployed, reducing MR from severe to trivial without thrombotic or bleeding complications. The patient recovered rapidly with immediate IABP removal and early extubation. DISCUSSION: This case demonstrates that M-TEER under argatroban anticoagulation can be a feasible alternative when conventional surgery is precluded by suspected HIT and the anticipated challenges of anticoagulation during cardiopulmonary bypass. TAKE-HOME MESSAGE: M-TEER under argatroban may serve as a rescue strategy for critically ill patients with acute severe MR and suspected HIT when surgical management is not feasible.