Division of Advanced Heart Failure and Cardiac Transplant, University of South Florida, Tampa General Hospital, 7110 S Trask Street, Tampa, FL, 33616, USA.
J Cardiothorac Surg. 2024 Nov 6;19(1):626. doi: 10.1186/s13019-024-03019-9.
Acute ischemic mitral regurgitation (AIMR) is a significant complication of acute coronary syndrome that leads to severe and immediate hemodynamic deterioration and cardiogenic shock. Intra-aortic balloon pumps (IABP) are commonly used to support patients with AIMR as a bridge to surgery, though they may be insufficient in some cases.
A 74-year-old male presented with two days of indigestion and evident hypoxia, and an electrocardiogram revealed inferior and lateral ST-elevation myocardial infarction. Angiography demonstrated severe two-vessel coronary disease with a 100% thrombotic occlusion of the second obtuse marginal artery (OM2, culprit lesion) and an 80% stenosis of the proximal left anterior descending artery (LAD). Despite stenting of OM2, the patient remained hypoxic and hypotensive, necessitating escalated support via an IABP. A follow-up echocardiogram revealed severe mitral regurgitation presumed to be AIMR secondary to a ruptured posteromedial papillary muscle with a flail anterior leaflet (A2). Despite aggressive supportive measures with the IABP, the patient's hemodynamics continued to show cardiogenic shock and clinical status did not improve. However, the patient was required to abstain from surgery for a P2Y12 inhibitor therapy wash out period. Consequently, the IABP was upgraded to Impella 5.5 as bridge-to-surgery support on day 1 post-admission. Subsequently, the patient's hemodynamics improved, and he underwent a combined mitral valve replacement and coronary artery bypass grafting surgery on day 7 post-admission without incident. The Impella was successfully explanted on day 25 post-admission. Delay in explant was due to hypotension and respiratory status despite normalizing hemodynamics and echocardiogram revealing recovered left ventricular ejection fraction. The patient developed bacterial pneumonia and acute respiratory distress syndrome and expired on day 27 post-admission.
Although IABP is standard for supporting AIMR patients as a bridge to surgery, it may not provide sufficient hemodynamic support. This case supports a growing body of evidence that alternative forms of hemodynamic support should be considered if the traditional therapeutic modalities for AIMR do not adequately support patients. Clinicians may consider upgrading IABP to Impella to provide increased hemodynamic support and maintain AIMR patient stability while awaiting cardiac surgery.
急性缺血性二尖瓣反流（AIMR）是急性冠状动脉综合征的一种严重并发症，可导致严重且即刻的血流动力学恶化和心源性休克。主动脉内球囊泵（IABP）常用于支持 AIMR 患者作为手术的桥梁，但在某些情况下可能不够。
一名 74 岁男性因两天消化不良和明显缺氧就诊，心电图显示下壁和外侧 ST 段抬高型心肌梗死。血管造影显示两支血管严重病变，第二钝缘支（OM2，罪犯病变）完全闭塞，左前降支近端 80%狭窄。尽管 OM2 支架置入后，患者仍缺氧低血压，需要通过 IABP 升级支持。后续超声心动图显示严重二尖瓣反流，推测为后内侧乳头肌破裂导致前瓣游离（A2）的 AIMR。尽管通过 IABP 积极支持治疗，但患者的血流动力学仍表现为心源性休克，临床状况无改善。然而，由于需要进行 P2Y12 抑制剂治疗洗脱期，患者不能进行手术。因此，入院后第 1 天将 IABP 升级为 Impella 5.5 以作为手术桥接支持。随后，患者的血流动力学改善，入院后第 7 天成功进行了二尖瓣置换和冠状动脉旁路移植术，无并发症。入院后第 25 天成功取出 Impella。尽管血流动力学和超声心动图显示左心室射血分数恢复正常，但由于低血压和呼吸状况延迟取出。患者发生细菌性肺炎和急性呼吸窘迫综合征，入院后第 27 天死亡。
虽然 IABP 是支持 AIMR 患者作为手术桥接的标准方法，但它可能无法提供足够的血流动力学支持。本病例支持越来越多的证据表明，如果传统的 AIMR 治疗方法不能充分支持患者，应考虑替代形式的血流动力学支持。临床医生可能会考虑将 IABP 升级为 Impella，以提供更高的血流动力学支持，并在等待心脏手术时维持 AIMR 患者的稳定性。
