Sobajima Mitsuo, Fukuda Nobuyuki, Ueno Hiroshi, Kinugawa Koichiro
The Second Department of Internal Medicine, Graduate School of Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan.
Eur Heart J Case Rep. 2020 Nov 5;4(6):1-5. doi: 10.1093/ehjcr/ytaa418. eCollection 2020 Dec.
The safety and efficacy of MitraClip for advanced heart failure (HF) patients who are inotrope-dependent or mechanically supported are unknown.
The patient was a 71-year-old man diagnosed as dilated cardiomyopathy in 2003. He was admitted due to worsening HF in January 2019 and became dependent upon intravenous infusion of inotropes. During the 8-month hospitalization, his haemodynamics were relatively static with bed rest and continuous inotropes, but he was definitely dependent on them. Our multidisciplinary team decided to perform both cardiac resynchronization therapy (CRT) and MitraClip under Impella support. First, Impella was inserted from left subclavian artery. After a week, CRT was implanted from right subclavian vein, and the QRS duration of electrocardiogram became remarkably narrow. MitraClip was performed 2 weeks after Impella, and functional mitral regurgitation improved from severe to mild, and Impella was removed on the same day. Inotropes could be ceased, and he was discharged 2 months after MitraClip.
During inotrope-dependent status, there was a risk that HF would worsen with haemodynamic collapse when performing CRT implantation, and we firstly supported his haemodynamics by Impella. Cardiac resynchronization therapy implantation before MitraClip seemed to be crucial. In fact, the mitral valve morphology before Impella insertion had very poor coaptation of the anterior and posterior leaflets that was not optimal for MitraClip procedure. But the Impella support and correction of dyssynchrony by CRT markedly improved the coaptation of those leaflets. The combination therapy of CRT and MitraClip unloading with Impella maybe a new therapeutic option for advanced HF.
对于依赖血管活性药物或接受机械支持的晚期心力衰竭（HF）患者，MitraClip的安全性和有效性尚不清楚。
患者为一名71岁男性，2003年被诊断为扩张型心肌病。2019年1月因HF恶化入院，开始依赖静脉输注血管活性药物。在8个月的住院期间，通过卧床休息和持续使用血管活性药物，他的血流动力学相对稳定，但他绝对依赖这些药物。我们的多学科团队决定在Impella支持下同时进行心脏再同步治疗（CRT）和MitraClip手术。首先，从左锁骨下动脉插入Impella。一周后，从右锁骨下静脉植入CRT，心电图的QRS波时限明显变窄。在插入Impella两周后进行MitraClip手术，功能性二尖瓣反流从重度改善为轻度，并于同日移除Impella。血管活性药物可以停用，MitraClip手术后2个月他出院了。
在依赖血管活性药物的状态下，进行CRT植入时存在HF因血流动力学崩溃而恶化的风险，我们首先通过Impella支持他的血流动力学。在MitraClip手术前植入心脏再同步治疗似乎至关重要。事实上，在插入Impella之前二尖瓣的形态显示前后叶对合很差，这对于MitraClip手术来说并非最佳状态。但Impella支持和CRT对不同步的纠正显著改善了这些叶瓣的对合情况。CRT与MitraClip联合Impella卸载治疗可能是晚期HF的一种新的治疗选择。
