Preoperative extracorporeal mechanical circulatory support for patients with acute severe mitral valve regurgitation due to papillary muscle necrosis

Background. Acute mitral valve insufficiency has a high mortality rate (up to 100%). Mechanical circulatory support and emergency surgery can improve the survival of this patient cohort.

Objectives: to analyze a 12-year single-center experience of treating acute post-infarction mitral valve insufficiency.

Materials and methods. This retrospective study included 12 adult patients with ST elevated myocardial infarction (STEMI) and corresponding acute mitral valve insufficiency who underwent surgery between 2009 and 2017. We analyzed the in-hospital period of all patients and long-term follow-ups whenever possible. All patients underwent preoperative coronary angiography and echocardiography. All patients underwent cardiopulmonary bypass and cold-blood cardio- plegia. If venoarterial extracorporeal membrane oxygenation (VA-ECMO) was required, the femoral approach was preferred.

Results. Seven patients needed VA-ECMO support, six of them preoperatively; four received mechanical circulatory support outside the hospital. All patients underwent percutaneous coronary intervention (PCI) with successful revascularization of the culprit artery. All but one patient underwent surgery within the first 24 hours. One patient underwent repeat surgery once the mitral valve could be repaired, and the other patient did not require any coronary bypass. In-hospital mortality occurred in one patient in the VA-ECMO group. Patients receiving VA-ECMO had longer duration of inotropic support, ventilation time, and intensive care unit stay (p < 0.01).

Conclusions. Acute mitral valve insufficiency due to STEMI remains a dramatic complication, but the perioperative use of VA-ECMO helps reduce 30-day mortality and improve outcomes in this group of patients.

1. El Sabbagh A, Reddy YNV, Nishimura RA. Mitral Valve Regurgitation in the Contemporary Era: Insights Into Diagnosis, Management, and Future Directions. JACC Cardiovasc Imaging. 2018; 11 (4): 628–643. doi: 10.1016/j.jcmg.2018.01.009.

2. Varma PK, Krishna N, Jose RL, Madkaiker AN. Ischemic Mitral Regurgitation. Ann Card Anaesth. 2017; 20 (4): 432–439. doi: 10.4103/aca.ACA.

3. Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009; 373 (9672): 1382–1394. doi: 10.1016/S0140-6736(09)60692-9.

4. Olson LJ, Subramanian R, Ackermann DM, Orszulak TA, Edwards WD. Surgical Pathology of the Mitral Valve: A Study of 712 Cases Spanning 21 Years. Mayo Clin Proc. 1987; 62 (1): 22–34. doi: 10.1016/S0025-6196(12)61522-5.

5. Borger MA, Alam A, Murphy PM, Doenst T, David TE. Chronic ischemic mitral regurgitation: Repair, replace or rethink? Ann Thorac Surg. 2006; 81 (3): 1153–1161. doi: 10.1016/j.athoracsur.2005.08.080.

6. Kettner J, Sramko M, Holek M, Pirk J, Kautzner J. Utility of Intra-Aortic Balloon Pump Support for Ventricular Septal Rupture and Acute Mitral Regurgitation Complicating Acute Myocardial Infarction. Am J Cardiol. 2013; 112 (11): 1709–1713.

7. Báez-Ferrer N, Izquierdo-Gómez MM, Marí-López B, Montoto-López J, Duque-Gómez A, García-Niebla J et al. Clinical manifestations, diagnosis, and treatment of ischemic mitral regurgitation: A review. J Thorac Dis. 2018; 10 (12): 6969–6986. doi: 10.21037/jtd.2018.10.64.

8. Birnbaum Y, Chamoun AJ, Conti VR, Uretsky BF. Mitral regurgitation following acute myocardial infarction. Coron Artery Dis. 2002; 13 (6): 337–344. doi: 10.1097/00019501-200209000-00006.

9. Sheu JJ, Tsai TH, Lee FY, Fang HY, Sun CK, Leu S et al. Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med. 2010; 38 (9): 1810–1817. doi: 10.1097/CCM.0b013e3181e8acf7.

10. Gillinov AM, Wierup PN, Blackstone EH, Bishay ES, Cosgrove DM, White J et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg. 2001; 122 (6): 1125–1141. doi: 10.1067/mtc.2001.116557.

11. Michler RE, Smith PK, Parides MK, Ailawadi G, Thourani V, Moskowitz AJ et al. Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med. 2016; 374 (20): 1932–1941. doi: 10.1056/NEJMoa1602003.

12. Kim TS, Na CY, Baek JH, Kim JH, Oh SS. Preoperative extracorporeal membrane oxygenation for severe ischemic mitral regurgitation – 2 Case reports. Korean J Thorac Cardiovasc Surg. 2011; 44 (3): 236–239. doi: 10.5090/kjtcs.2011.44.3.236.

13. Kilic A, Sultan I, Chu D, Wang Y, Gleason TG. Mitral Valve Surgery for Papillary Muscle Rupture: Outcomes in 1,342 Patients from the STS Database. Ann Thorac Surg. 2020; 110 (6): 1975–1981. doi: 10.1016/j.athoracsur.2020.03.097.

14. Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: An executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2013; 14 (7): 611–644. doi: 10.1093/ehjci/jet105.

15. Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017; 52 (4): 616–664. doi: 10.1093/ejcts/ezx324.

16. Baran DA, Grines CL, Bailey S, Burkhoff D, Hall SA, Henry TD et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. 2019; 94 (1): 29–37. doi: 10.1002/ccd.28329. Epub 2019 May 19.

17. Elbadawi A, Elgendy IY, Mahmoud K, Barakat AF, Mentias A, Mohamed AH et al. Temporal Trends and Outcomes of Mechanical Complications in Patients With Acute Myocardial Infarction. JACC: Cardiovascular Interv. 2019; 12 (18): 1825–1836. doi: 10.1016/j.jcin.2019.04.039.

18. Briosa E Gala A, Hinton J, Sirohi R. Cardiogenic shock due to acute severe ischemic mitral regurgitation. Am J Emerg Med. 2021; 43: 292.e1–292.e3. doi: 10.1016/j.ajem.2020.10.028.