Pallavi Bellamkonda

Background: Severe mitral regurgitation (MR) in cardiogenic shock (CS) presents unique therapeutic challenges, especially in patients with prohibitive surgical risk. Transcatheter edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative, yet optimal strategies for hemodynamic support in this setting remain unclear. Methods: We conducted a retrospective study of patients undergoing MitraClip implantation for severe MR and CS between 2018 and 2024 at a tertiary academic center. Of 440 screened cases, 47 met CS criteria and were stratified based on receipt of periprocedural Impella support. Clinical, procedural, and survival outcomes were compared between Impella-supported and unsupported cohorts using appropriate statistical methods. Results: Among the 47 patients, 24 received Impella support and 23 did not. The Impella group had greater illness severity, including higher rates of preprocedural intubation (75.0% vs. 43.5%) and SCAI stage D shock (50.0% vs. 13.0%). Despite these differences, procedural success was 100% in both groups. In-hospital (8.3% vs. 8.7%), 30-day (12.5% vs. 8.7%), and 1-year mortality (25.0% vs. 26.0%) were similar between Impella and non-Impella patients, respectively. Impella recipients had longer hospital stays (median 18 vs. 11 days; p=0.032) and higher 1-year readmission rates (55.0% vs. 21.7%; p=0.024), reflecting baseline acuity. There were no differences in major procedural complications or re-intervention rates. Conclusions: MitraClip implantation in CS patients supported with Impella is feasible and safe. Despite significantly worse hemodynamic profiles, outcomes were comparable to those without mechanical support. These findings suggest a potential role for tailored Impella use in expanding TEER to critically ill patients and underscore the need for prospective studies to guide support strategies in high-risk MR intervention.

Severe mitral regurgitation (MR) is associated with significant morbidity and mortality, particularly in patients with shock. While surgical repair remains the standard of care in acute primary MR, many critically ill patients are ineligible due to advanced age or comorbidities. Transcatheter edge-to-edge mitral valve repair (TEER) with MitraClip has emerged as a promising alternative. Unlike prior registries, this study directly compares cardiogenic vs. mixed shock using invasive criteria, integrates SCAI staging, BOS-MA2 risk prediction, and valve phenotyping, and highlights the need for prospective studies to refine patient selection. To evaluate the feasibility, safety, and clinical outcomes of MitraClip implantation in patients with severe MR and cardiogenic or mixed shock. This retrospective cohort study analyzed 47 patients with severe MR and cardiogenic (n = 32) or mixed shock (n = 15) treated with MitraClip between January 2017 and December 2023. Procedural success, defined as successful clip deployment, reduction of MR to ≤2, and absence of major device-related complications, was assessed alongside short- and long-term outcomes. Baseline characteristics, hemodynamic parameters, and outcomes were compared between shock subtypes. Procedural success was achieved in 100 % of cases. MR severity improved significantly from grade 4 to grade ≤ 2 (p < 0.001). In-hospital mortality was 8.5 %, and 1-year mortality was 25.5 %. Patients with mixed shock had higher in-hospital mortality (20 % vs. 3.1 %, p = 0.53) and lower 1-year readmission rates (21.4 % vs. 58.6 %, p = 0.02). Predictors of 1-year mortality included advanced age, elevated left atrial volume index, and prolonged vasopressor use. MitraClip implantation is a feasible intervention for severe MR in patients with shock, demonstrating high procedural success and meaningful reductions in MR severity across both cardiogenic and mixed shock. These exploratory findings highlight the need for larger prospective studies to validate outcomes and refine patient selection. •MitraClip was safely used in all patients with severe mitral regurgitation and shock.•Most patients had mitral regurgitation reduced to mild or less after the procedure.•In-hospital mortality was low despite high predicted risk in this critically ill cohort.•One-year readmissions were lower in mixed shock compared to cardiogenic shock.•Older age, large left atrial volume, and vasopressor use predicted worse survival.

DiGeorge syndrome (22q11.2 deletion syndrome) is associated with complex congenital heart defects, including truncus arteriosus. Aortic valve insufficiency after bioprosthetic valve replacement is rare but can lead to cardiogenic shock. A 16-year-old girl with DiGeorge syndrome and truncus arteriosus presented with cardiogenic shock and severe aortic insufficiency. Initial stabilization with inotropes and mechanical ventilation failed, necessitating left atrial venoarterial extracorporeal membrane oxygenation (LAVA ECMO). Following her stabilization, transcatheter aortic valve replacement (TAVR) was performed, resulting in rapid hemodynamic improvement. This case demonstrates the successful use of LAVA ECMO and TAVR in managing bioprosthetic valve dysfunction and cardiogenic shock in a high-risk patient. The case underscores the importance of advanced cardiovascular interventions and multidisciplinary care, in line with current guidelines, for managing similar complex scenarios. [Display omitted]

Myocardial infarction with non-obstructive coronary arteries (MINOCA) presents a diagnostic challenge due to its heterogeneous etiologies and the absence of obstructive coronary lesions. We report the case of a 74-year-old male with hypertension, prior deep vein thrombosis, and a history suggestive of thrombophilia under evaluation, on chronic warfarin therapy, who presented with chest pain, ST elevation, and elevated troponins. Coronary angiography revealed no obstructive coronary artery disease. Cardiac magnetic resonance imaging (MRI) demonstrated an acute transmural myocardial infarction with microvascular obstruction in the left anterior descending artery region. Alternative cardiac and extracardiac causes were excluded, and the diagnosis was revised to MINOCA. This case underscores the diagnostic power of cardiac MRI and suggests spontaneous thrombolysis as a plausible mechanism, based on the transmural infarction pattern, presence of microvascular obstruction, and absence of angiographic obstruction.

Abstract only Introduction: Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide. In the quest for improved therapeutic strategies, the addition of Sodium Glucose Transporter Inhibitors (SGLTis) to the treatment regimen has garnered considerable attention. This meta-analysis endeavors to shed light on the efficacy of SGLTis in short-term cardio-renal protection post-AMI. By synthesizing evidence from diverse studies. Methods: Adhering to the PRISMA guidelines, a meticulous systematic review and meta-analysis were conducted. Comprehensive literature searches across PubMed, Web of Science, Scopes, and Google Scholar were performed. Inclusion criteria comprised four Randomized Controlled Trials (RCTs), one retrospective cohort, and one observational study, investigating the effects of SGLTis versus placebo on AMI patients, irrespective of diabetic status. Our analysis included the following outcomes: acute kidney injury, all-cause death, cardiovascular mortality, cardiac death, composite of cardiovascular death/hospitalization for heart failure, and NT-proBNP levels. Results: Our analysis encompassed six scientific articles involving 7238 patients. SGLTIs exhibited a notable favorable effect solely on acute kidney injury (P value=0.001, 95% CI [0.46-0.82]). Conversely, no significant benefit was observed in other short-term outcomes, including all-cause death, cardiovascular mortality, cardiac death, composite of cardiovascular death/hospitalization for heart failure, and NT-proBNP levels. These results align with previous studies suggesting the renal protective effects of SGLTIs but highlight the need for further research to clarify their overall cardiovascular benefits in AMI patients. Conclusion: Incorporating SGLTis into the therapeutic armamentarium of AMI patients, irrespective of diabetic status, demonstrated a discernible advantage solely concerning acute kidney injury. However, no appreciable benefit was discerned across other assessed metrics. These findings underscore the need for further exploration and tailored therapeutic strategies in the management of post-AMI patients.