SPC365

Afterload-dependent severe mitral regurgitation: seak and you will find

Session: Prémio Melhor Caso Clínico
Speaker: Carolina Pereira Mateus

Congress: CPC 2023
Topic: P. Other
Theme: 37. Miscellanea
Subtheme: ---
Session Type: Sessão de Prémios
FP Number: ---
Authors: Carolina Pereira Mateus; Mariana Passos; Inês Fialho; Joana Lopes; Inês Miranda; Filipa Gerardo; João Baltazar Ferreira; Carlos Morais; António Freitas; Ana Oliveira Soares; David Roque
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">We present the case of a 72-year-old male patient</span></span>&nbsp;<span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">with past medical history of Heart Failure (HF) with reduced Ejection Fraction (EF), due to a STEMI in 2014 (primary PCI of the RCA; diffuse atherosclerosis of the left anterior descending artery and first diagonal, not suitable for revascularization; TTE at this time with akinesia of the inferior wall, meso-apical hypokinesia&nbsp;of the lateral and anterior wall, and a EF of 35%); paroxysmal atrial fibrillation; hypertension; dyslipidemia and peripheral artery disease.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">A CRT-D was implanted in 2015. The patient was in NYHA functional class II with guideline directed medical therapy (GDMT).</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">From March 2021 to October 2022, he had a total of 11 hospital admissions due to sudden dyspnea&nbsp;associated with a hypertensive spike, with&nbsp;respiratory acidosis and need of&nbsp;Non-Invasive Ventilation (and Invasive Ventilation in one of them), as well as endovenous nitrates and diuretics.&nbsp;All these events had a quick resolution with discharge in 2 to 5 days. Even though GDMT was optimized, he&nbsp;kept having acute decompensations of HF. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">Consecutives TTEs during these hospital admissions, showed a dilated left ventricle (TDd 60mm), EF of 35%, mild functional mitral regurgitation (MR) and normal morphology of the mitral valve apparatus, mild tricuspid regurgitation.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">Considering the multiple hospital admissions in what seemed to resemble a picture of &ldquo;flash pulmonary edema&rdquo;, a stress echocardiography was performed,&nbsp;starting at 20W with increments of 15W every 3 minutes. After 4 minutes, the exam was interrupted due to severe dyspnea and showed: BP 180/80mmHg (T<sub>0</sub>&nbsp;125/68mmHg), worsening MR (no quantitative measures were calculated due to the abrupt cessation of the exam), increment of left ventricle filling pressures (E/E&rsquo; 10 to 23), elevation of SPAP to 60mmHg and diffuse, bilateral B-lines.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">We then performed a TTE with a continuous perfusion of phenylephrine, a pure vasoconstrictor, until BP increased to 180/82mmHg, showing severe MR (ERO 40mm<sup>2</sup>, RV 75mL/beat) (Figure 1).</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">Since the patient suited the COAPT profile,&nbsp;he was proposed to MitraClip implantation, which was performed in November 2022, with a single clip implanted in A2-P2 (before intervention: Figure 2). By the end of the procedure, the MR&nbsp;was mild, central, and non-holosystolic&nbsp;even with SBP of 150mmHg.&nbsp;There were no complications.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">On 2-month follow-up, the patient had no readmissions and improved his functional status. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="font-size:11.0pt"><span style="font-family:&quot;Calibri&quot;,sans-serif">We here report a case of multiple hospital admissions despite GDMT, which&nbsp;shows&nbsp;the need of evaluating these non-ordinary patients in non-usual ways, since the evaluation at rest can sometimes hinder the pathophysiologic mechanism behind the acute decompensation.&nbsp;In this case, an afterload-dependent severe mitral regurgitation was corrected, translating in improved functional status, quality of life and avoidance of new hospital admissions.</span></span></span></span></p>