key: cord-0830945-cejw22ms
authors: Chitturi, Kalyan R.; Faza, Nadeen N.; Little, Stephen H.; Kleiman, Neal S.; Reardon, Michael J.; Goel, Sachin S.
title: Transcatheter mitral valve repair with MitraClip for severe mitral regurgitation and cardiogenic shock during the COVID-19 pandemic
date: 2020-05-23
journal: Cardiovasc Revasc Med
DOI: 10.1016/j.carrev.2020.05.030
sha: f4aa1275c5d2d5ddf212bcaa9d0b7b872aa94427
doc_id: 830945
cord_uid: cejw22ms

Transcatheter mitral valve repair with MitraClip (Abbott) is largely an elective procedure. The ongoing coronavirus disease 2019 (COVID-19) pandemic has posed challenges to health care systems; in many cases elective interventions have been curtailed. Patients with severe mitral regurgitation (MR) and cardiogenic shock are high-risk surgical candidates and at risk of a poor outcome without intervention. The American College of Cardiology (ACC) and the Society of Coronary Angiography and Interventions (SCAI) recently proposed joint guidance on triage of structural heart disease (SHD) interventions during the COVID-19 pandemic. We present two illustrative cases of severe MR and cardiogenic shock that were successfully treated with MitraClip amidst the COVID-19 pandemic with good outcomes at short term follow-up.

Coronavirus disease 2019 (COVID-19) is contracted from exposure to SARS-CoV-2, a highly contagious virus that has spread globally, straining the health care resources of many nations. Patients with structural heart disease (SHD) are not only vulnerable to COVID-19 by way of age and co-morbidities, but also impacted indirectly by systemic effects of the pandemic as heavily burdened health care systems divert or limit anesthesia care, ventilators, intensive care unit (ICU) beds, and personal protective equipment (PPE). Since delayed treatment of SHD in some cases can be associated with significant morbidity and mortality, leaders in SHD and representative organizations American College of Cardiology (ACC) and Society of Coronary Angiography and Interventions (SCAI) have outlined guidance for triaging transcatheter interventions given the current resource constraints and public and occupational health concerns. 1, 2 Patients with severe mitral regurgitation (MR) and cardiogenic shock are often at prohibitive surgical risk, and randomized controlled trials of percutaneous mitral valve (MV) repair have excluded such patients. 3, 4 Applying the above consensus statement, we describe two cases of severe MR and shock that presented treatment challenges amidst the COVID-19 pandemic.

A 56-year-old man with a history of non-ischemic cardiomyopathy, prior automated internal cardioverter defibrillator (AICD) implantation, non-obstructive coronary artery disease Following the procedure, the patient improved hemodynamically, with weaning and removal of the IABP the following day and titration off milrinone two days later. Post-procedure TTE confirmed mild residual MR. Multisystem organ failure resolved after three additional days in the ICU, and the patient was discharged in stable condition seven days after the procedure. At one-month follow-up performed via telemedicine, the patient continues to report significant functional improvement (NYHA Class II).

A 60-year-old man presented to the emergency department with progressive exertional dyspnea (NYHA Class IV), bilateral lower extremity edema, and a clinical examination consistent with decompensated CHF. His history was significant for severe degenerative MR due to a posterior flail leaflet from chord rupture, which had been diagnosed six weeks previously. pandemic. While all elective cases were deferred, in accordance with the consensus statement by ACC and SCAI, we proceeded with transcatheter MV intervention for these two highly selected patients.

With the onset of the COVID-19 pandemic, we took several steps regarding our SHD program. The majority of outpatient clinic appointments were converted to telemedicine encounters. Patients with SHD that did not meet the criteria listed in the ACC/SCAI consensus statement for interventions were placed on a "deferred list" which included most of our planned mitral interventional cases. The SHD team continued to convene virtually every week to review the status of the deferred patients and review any new cases referred for intervention. Patients who were deferred were notified by telephone weekly to ensure their symptoms were stable and not progressive. 

The Restructuring of Structural Heart Disease Practice During The Covid-19 Pandemic

Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the Coronavirus Disease 2019 (COVID-19) Pandemic: An ACC /SCAI Consensus Statement

Percutaneous repair or surgery for mitral regurgitation

Transcatheter Mitral-Valve Repair in Patients with Heart Failure

Percutaneous Mitral Repair for Patients in Cardiogenic Shock Requiring Inotropes and Temporary Mechanical Circulatory Support

Percutaneous edge-to-edge mitral valve repair may rescue select patients in cardiogenic shock: Findings from a single center case series

Isolated Mitral Valve Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

Outcomes With Transcatheter Mitral Valve Repair in the United States: An STS/ACC TVT Registry Report