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CASE REPORT
Year : 2023 | Volume
: 24
| Issue : 3 | Page : 160-162
Acute mitral regurgitation with unilateral left-sided pulmonary edema: A complication of stemi treated successfully with a mitraclip procedure
Ibrar Anjum1, Umer Zia1, Sheraz Anjum1, Shalin Patel2
1 Department of Internal Medicine, Vassar Brothers Medical Center Poughkeepsie, New York, USA
2 Department of Cardiology, Vassar Brothers Medical Center Poughkeepsie, New York, USA
Correspondence Address:
Dr. Ibrar Anjum
Department of Internal Medicine, Nuvance Health – Vassar Brothers Medical Center, Poughkeepsie, NY
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_108_22
Abstract
A 67-year-old man with inferior wall ST-segment elevation myocardial infarction underwent Impella-assisted percutaneous coronary intervention complicated by unilateral left-sided pulmonary edema and cardiogenic shock due to severe mitral valve regurgitation. Surgery was deferred due to hemodynamic instability and a high risk of mortality, so he underwent a MitraClip procedure. Mitral regurgitation (MR) is a catastrophic mechanical complication of myocardial infarction that leads to the development of pulmonary edema, cardiogenic shock, and death. After the procedure, the patient significantly reduces MR with a resolution of pulmonary edema. Acute MR can rarely present as a unilateral left-sided pulmonary edema delaying diagnosis and treatment. Transcatheter edge-to-edge repair can be a safe alternative for patients who are at high risk for surgery.
Keywords: Acute mitral regurgitation, MitraClip procedure, unilateral pulmonary edema in acute mitral regurgitation
Introduction 
Acute myocardial infarction complicated by cardiogenic shock due to mitral valve regurgitation carries a high risk of mortality of up to 5%.[1] A typical X-ray chest finding is bilateral pulmonary edema.
Unilateral cardiogenic pulmonary edema is rare and often misdiagnosed as a respiratory disease, resulting in a delay in treatment and a high mortality rate.[2] Traditionally, the definitive treatment of mitral valve regurgitation is surgical intervention. Percutaneous repair of mitral regurgitation (MR) with a MitraClip device is becoming a more feasible therapeutic option in critically ill and hemodynamic unstable patients.
We present a case of myocardial infarction complicated by acute MR with left-sided pulmonary edema successfully treated with a transcutaneous MitralClip procedure.
Case Presentation A 67-year-old man with a history of hypertension was brought in by ambulance to the emergency department for midsternal chest pain and nausea. Physical examination showed a pulse rate of 85 bpm, blood pressure of 108/72 mmHg, respiratory rate of 19/min, and 92% oxygen saturation on 2 L nasal cannula oxygen support. The echocardiogram (EKG) showed ST elevations in II, III, and aVF with reciprocal depressions in I, aVL, and V2–V6 [Figure 1]. The patient was urgently transferred to the cath laboratory for percutaneous coronary intervention (PCI), during which, the patient developed ventricular fibrillation arrest and cardiogenic shock. The patient was successfully intubated and stabilized with an Impella device. Cardiothoracic surgery deferred emergent coronary artery bypass grafting because of the patient's excessive risk procedure.
Figure 1: EKG showed ST elevations in II, III, aVF with reciprocal depressions in I, aVL, V2-V6. EKG: EchocardiogramTransesophageal EKG demonstrated moderate-to-severe MR without evidence of papillary muscle dysfunction. Coronary angiography showed flow-limiting stenosis in the left main coronary artery, left anterior descending artery, and circumflex coronary artery, followed by balloon angioplasty and implantation of drug-eluting stents.
Two days after PCI, the patient was hemodynamically improved, Impella support was removed, and the patient was extubated. The next day patient developed acute pulmonary edema requiring reintubation. Chest X-ray showed evidence of unilateral left-sided pulmonary edema [Figure 2], which was supportive of severe eccentric MR with a jet directed toward the left-sided pulmonary veins. Repeat transthoracic echo showed an ejection fraction of 50%–55% with mild inferobasal hypokinesia. Repeat transesophageal echo (TEE) showed severe mitral insufficiency with the flail of P2 (Clip 1).
Figure 2: Chest X-ray showed evidence of pulmonary edema, prominent on the left sideThe patient was not a good candidate for surgical repair of the mitral valve due to his critical condition and high risk of mortality. Therefore, the patient underwent the edge-to-edge transcutaneous MitraClip procedure. An XTW clip was implanted in the A2-P2 position under TEE guidance with excellent positioning (Clip 2).
After the clip procedure, MR was effectively reduced from severe + 4 to mild–moderate + 2. Repeat echo showed a mean transmitral gradient of 5.5 mmHg. A repeat X-ray chest was negative for pulmonary edema. The patient was hemodynamically stable but failed multiple trials of extubation due to altered mental status. Subsequently, the patient underwent a tracheostomy tube procedure, and he was discharged to LTACH (long-term care).
Discussion Severe acute MR is a serious complication of myocardial infarction and demands urgent surgical and medical intervention due to the high risk of mortality.
This patient developed a sudden increase in left atrial pressure due to the backward flow of volume without acute remodeling of the left atrial and ventricular chambers. Chest X-ray usually shows bilateral symmetrical infiltration due to pulmonary congestion.[3] Unilateral pulmonary edema is a rare finding and represents 2% of cardiogenic pulmonary edema.[2] Due to misdiagnosis and delayed treatment, the mortality rate is twice that compared to bilateral pulmonary edema.[4] In our case, the cause of left-sided pulmonary edema was due to sudden mitral valve regurgitation with an eccentric jet directed toward the left-sided pulmonary veins of the left atrium.
The traditional approach involves medical stabilization and surgical intervention to address the specific etiology of valvular dysfunction.[5] Percutaneous edge-to-edge repair of acute MR is becoming more popular and is potentially a life-saving approach, especially in high-risk surgical candidates. This procedure is also an option for high-risk surgical inoperable patients as per (American College of Cardiology/American Heart Association and European Society of Cardiology guidelines).[6],[7] In our case, the decision to proceed with MitraClip was due to high surgical risk due to PCI and dual antiplatelet therapy, hemodynamic instability, and cardiogenic shock. The patient went through a clipping procedure with an effective reduction of MR from severe to mild–moderate degrees.
Conclusion Acute MR is a life-threatening complication of MI that can present as a unilateral left-sided pulmonary edema which delays diagnosis and prompt treatment. Treating these patients with edge-to-edge repair can be a safe and effective alternative option for patients who are not ideal surgical candidates.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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