Urgent Appropriately Indicated MitraClip Procedure in Patient with Cardiogenic Shock in Covid-19 Era – May 2020

Case and Plan:

74-year-old male former smoker with PMHx of HTN, HLD, and A Fib (on Eliquis) had IW-STEMI on 02/09/20. Cath showed occluded mRCA with dLM bifurcation disease; S/p DES-PPCI to mRCA. Transthoracic echocardiogram at the time of discharge showed an EF of 55% with moderate MR. Pt had staged PCI to dLM (Mini-crush technique- Rota guided, Impella supported DES-PCI) on 03/17/20. He was discharged the next day. Pt was readmitted 2 days later at an OSH via EMS due to breathlessness and unresponsiveness. He had transient cardiac arrest and was successfully resuscitated. He was also intubated due to impending respiratory failure, and was started on vasopressors and diuretics. EKG showed no acute ischemic changes with troponin of 0.59 and COVID was negative. He was transferred to MSH. A repeat cath showed patent stents with moderate pulmonary artery hypertension and markedly elevated PCW pressure (mean/V wave: 30/55). An IABP was placed. A subsequent TEE showed severe eccentric MR with flail A2. Heart team found him to be an appropriate candidate for urgent MitraClip procedure given the COVID pandemic. He underwent a successful MitraClip procedure following which he was extubated and IABP was removed. He was discharged 3 days later.