Cardiogenic Shock Secondary to Acute Mitral Regurgitation With Nonischemic Etiology Successfully Stabilized by Transcatheter Intervention

Figure 1. Electrocardiogram, atrial fibrillation with rapid ventricular rate, right-axis deviation.

Figure 2. Portable chest x-ray on admission. Cardiomegaly and pulmonary vascular congestion with suspected interstitial pulmonary edema.

Figure 3. Transthoracic echocardiogram (systolic frame). (A) Parasternal long-axis view indicated chordal rupture and a flail segment of posterior leaflet. (B) Parasternal long-axis view with color Doppler demonstrates severe anteriorly directed jet of MR. (C) Apical 4-chamber view reveals severe anteriorly directed jet of MR. (D) Parasternal basal, short-axis view suggests a likely flail P2 segment of the posterior leaflet.

Figure 4. Periprocedural transesophageal echocardiogram, midesophageal views focusing on the MV in systole. (A) Three-dimensional reconstruction image prior to TMVEER demonstrates severe anteriorly directed MR. (B) Three-dimensional reconstruction image after first TMVEER to A2,P2 demonstrates significantly reduced MR. (C) Three-dimensional reconstruction image after second TMVEER demonstrates nearly completely resolved MR. (D) Two-dimensional transesophageal echocardiogram with color at 62° view prior to TMVEER demonstrates posterior leaflet prolapse with severe anteriorly directed MR. (E) Two-dimensional transesophageal echocardiogram without and with color at 55° view after first TMVEER to A2,P2 demonstrates moderate MR medial to the deployed device. (F) Two-dimensional transesophageal echocardiogram without and with color at 71° view after second TMVEER to A2,P2 demonstrates mild MR.

Figure 5. Periprocedural pulsed-wave and continuous-wave Doppler pulmonary vein and MV findings. (A) Pulmonary vein flow prior to TMVEER demonstrates blunted systolic velocity (<30 cm/sec). (B) Pulmonary vein flow after TMVEER demonstrates restored systolic velocity (>60 cm/sec). (C) Trans-MV gradient prior to TMVEER demonstrates a mean gradient of 2 mm Hg, which is increased to 5 mm Hg after TMVEER (D).

Figure 6. Follow-up TTE, apical 4-chamber view, systolic frame, without (A) and with (B) color Doppler prior to surgical replacement demonstrates severe anteriorly directed MR with a well-seated device seen on the MV.

Figure 7. Representative histopathological images from resected tissues. (A) Gross pathological image of the resected MV demonstrates the leaflet and chordal tissue and the attached TMVEER devices. (B) Hematoxylin and eosin staining demonstrates no significant infiltrating cells in spongiosa area. (C) Masson trichrome staining demonstrates diminished and loose collagen in the fibrosa layer (arrows). (D) Alcian blue staining demonstrates excessive deposition of proteoglycan in the fibrosa and spongiosa areas of the atrialis and ventrialis tissues (arrowheads). Collectively, those pathological features suggest likely degenerative changes rather than inflammatory or ischemic changes.

Figure 8. Timeline.

Figure 9. Representative images of angiography. (A) Right coronary angiography. (B) Left coronary angiography. No significant stenosis was appreciated from either the left or right coronary artery system.