Case Study: a 59-year-old woman presented to the emergency department severely hypoxic with 1 day history of cough and breathlessness and radiological evidence of right-sided pulmonary consolidation suggesting community acquired pneumonia. She was initiated on antibiotics and non-invasive ventilation, however she deteriorated within 48 hours requiring invasive ventilation and multi organ support. Initial FoCUS demonstrated eccentric severe MR with one image suggesting a possible vegetation on the mitral valve.
She was transferred for further management to a regional cardiothoracic centre. Her transesophageal echocardiogram revealed torrential MR due to flail of P3 with a ruptured chordae and P2 prolapse (Image 1), a low cardiac output despite an apparently hyperdynamic LV, and no features of infective endocarditis. An Impella® 2.5 was inserted as a bridge to definitive treatment.
She was discussed by the MDTs (shock team, mitral team, critical care, specialist imaging) and after significant improvement (complete resolution of pulmonary oedema, minimal inotropes, normalisation of liver and kidney function), underwent successful percutaneous mitral valve repair day 10 post-admission. She was successfully extubated on day 1 and ultimately discharged home 19 days after initial presentation.
Conclusions: In CS, current guidelines recommend inotropes, respiratory support and early implementation of MCS, alongside with interventions to reverse the underlying cause. Mortality remains high in severe MR with the use of IABP alone, likely related to the degree of unresolved pulmonary oedema and poor organ perfusion resulting in multi-organ failure. Where right ventricular dysfunction is not a concern, devices such as the Impella®, might offer more favourable haemodynamic support and reverse organ dysfunction.
Another important consideration in severe MR are the numerous novel percutaneous interventions which are in development, highlighting the necessity of early expert imaging and multi-specialist team consultations to create an individualised management strategy and thus optimise outcomes.