Author + information
- Received December 15, 2015
- Revision received December 21, 2015
- Accepted December 28, 2015
- Published online April 11, 2016.
- aCardiology Section, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
- bCardiac Anesthesia, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
- ↵∗Reprint requests and correspondence:
Dr. Jason Foerst, Virginia Tech Carilion School of Medicine, 201 Crystal Springs, Roanoke, Virginia 24014.
A 90-year-old man with heart failure secondary to severe P2 prolapse and severe mitral regurgitation (MR) was deemed at prohibitive risk for surgical repair and placement of a MitraClip (Abbott Vascular, Santa Clara, California) planned. Shortly after induction of anesthesia, he became profoundly hypotensive refractory to vasopressors, requiring cardiopulmonary resuscitation and ultimately emergent delivery of an Impella CP (Abiomed, Danvers, Massachusetts). This stabilized his blood pressure, and we then proceeded with the procedure. There was a wide MR jet along the P2 segment, and we opted to clip in the middle, which bisected the jet (Figure 1). The mean mitral gradient was 2 mm Hg, and the valve orifice appeared adequate; thus, we proceeded with a second clip placed medial to the first along the P2. This resolved the medial jet, and there was just a residual lateral jet. Given the degree of afterload reduction with the Impella, we assumed that any residual MR would be much worse once the Impella weaned, and therefore we placed a third clip laterally after confirming a 3-mm Hg mitral gradient. The third clip was placed just lateral to the first, mitigating essentially all of the MR, and the pressors and Impella were weaned. We stopped the anesthesia and extubated on the table with the Impella still in place. The blood pressure was pulsatile, and pressors weaned nearly off, so we explanted the Impella. He had complete hemodynamic recovery and was discharged on postoperative day 2 with essentially no residual MR (Figure 2). To our knowledge, this is the first reported case of an Impella in place during MitraClip implantation and may prove a useful combination for the treatment of MR and cardiogenic shock.
Dr. Foerst is a consultant for Medtronic; and on the Speakers Bureau of St. Jude Medical and Edwards Lifesciences. The other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 15, 2015.
- Revision received December 21, 2015.
- Accepted December 28, 2015.
- American College of Cardiology Foundation