A Bridge too good

Valve disease Clinical case

Heart Failure With Severe Mitral Regurgitation

Author: Saleh Altaf, Owais Dar 
Affiliated institution: Harefield Hospital, Guy’s and St Thomas’ NHS Foundation Trust 
Conflict of interest: None

A Bridge too good
Saleh Altaf
Saleh Altaf
Fellow
United Kingdom
Dar Owais
Owais Dar
Cardiologist
United Kingdom
Case presentation

    A male in his mid-30s, with BMI of 19.5 kg/m2, and three heart failure hospitalisations in last six months, presented with one month history of gradually worsening shortness of breath on exertion and bilateral leg oedema.

    His past medical history included: 

    • Ischaemic heart disease – 1 year ago
      • Occluded LAD with no viability on cardiac MRI
      • PCI to proximal LCx
    • Heart failure with reduced ejection fraction of 30%
    • Primary prevention ICD
    • Severe ischaemic secondary mitral regurgitation 
    • Hyperlipidaemia

    Social:

    • Occasional ex-smoker
    • Socially drank alcohol in past, now abstinent

    Weight:

    • 57.1 Kg

    Height:

    • 171 cm

    Medications: 

    Our patient was taking following medications prior to admission:

    • Aspirin 75 mg OD
    • Atorvastatin 80 mg OD
    • Bisoprolol 2.5 mg OD
    • Dapagliflozin 10 mg OD
    • Eplerenone 25 mg OD
    • Sacubitril/Valsartan 24/26 mg BD
    • Furosemide 40 mg BD

    He had no known drug allergies 

    On examination patient’s blood pressure was 92/60 mm Hg, heart rate was 88 beats per minute, chest was clear with no crepitations, jugular venous pressure of 14 cm, normal heart sounds with a pan-systolic murmur and bilateral leg oedema till just below knees. He did not have hepatomegaly or ascites. 

    Investigations on admission:

    Haemoglobin: 133 g/L
    White blood cell count: 7.1 x 109/L
    Platelets: 204 x 109/L
    Creatinine: 83 µmole/L
    Alanine aminotransferase: 137 U/L
    Alkaline phosphatase: 188  U/L
    Total bilirubin: 17 µmole/L
    NT-ProBNP: 5274 ng/L
    ECG: Sinus rhythm at 87 beats/min, P-mitrale, narrow QRS with right bundle branch block morphology, with Q waves in I, aVL, V6.
    Chest X-Ray: Clear well inflated lungs.

    Based on presentation, patient was diagnosed with acute decompensation of advanced heart failure NYHA (New York heart association) class IV and treatment with intravenous furosemide 80 mg BD was started.

    Transthoracic echocardiogram (TTE) on admission:

    • Severely dilated LV with EF: 17%
    • Dilated RV
    • Severe MR, moderate TR
    • PSAP: 71 mm Hg

    Repeat TTE 10 days after admission: 

    • Severely dilated LV, LVEF: 29%, LVOT VTI: 6.5 cm, LVIDd I:  4.52 cm/m2, LVIDs I 3.89 cm/m2,  LVEDV I: 135.1 ml/m2 
    • Severely dilated LA
    • Dilated RV. TAPSE:  1.49 cm
    • Severely dilated RA
    • Severe MR, EROA: 0.38cm2
    • Moderate TR. 

    Figure 1: TTE colour doppler showing severe MR and moderate TR

    Right heart catheterisation result
     Baseline10-minutes after starting milrinone infusion at 5 mcg/kg/min
    BP (non-invasive, mm Hg)80/51 MAP: 6195/58 MAP: 71
    RA pressure (mm Hg)116
    RV pressure (mm Hg)56/9 EDP: 1034/4 EDP: 8
    PA pressure (mm Hg)57/33 Mean: 4232/19 Mean: 24
    PCWP (mm Hg)2714
    TPG (mm Hg)1510
    Cardiac output Fick's (L/min)2.845.01
    Cardiac index (L/min/m2)1.861.99
    PVR (Wood units)5.281.99
    SVR (dynes/sec/cm5)14081021
    Cardiopulmonary exercise test
    Peak VO218.6 ml/Kg/min (39% of predicted)
    VE/VCO2 slope35
    RER:1.19 
    Anaerobic threshold12.9 ml/Kg/min
     

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References
    1. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal. 2021;42(36):3599-726.
    2. Pagnesi M, Ghiraldin D, Vizzardi E, Chiarito M, Stolfo D, Baldetti L, et al. Detailed Assessment of the “I Need Help” Criteria in Patients With Heart Failure: Insights From the HELP-HF Registry. Circulation: Heart Failure. 2023;16(12):e011003.
    3. Pagnesi M, Lombardi CM, Chiarito M, Stolfo D, Baldetti L, Loiacono F, et al. Prognostic impact of the updated 2018 HFA-ESC definition of advanced heart failure: results from the HELP-HF registry. Eur J Heart Fail. 2022;24(9):1493-503.
    4. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2021;43(7):561-632.
    5. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim DS, Mishell JM, et al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. New England Journal of Medicine. 2018;379(24):2307-18.
    6. Marcelli C, Munafo' AR, Estevez-Loureiro R, Adamo M, Guerin P, Arzamendi D, et al. Transcatheter edge to edge repair of functional mitral regurgitation as bridge to heart transplantation: 2-years follow up results from MitraBridge international registry. European Heart Journal. 2023;44(Supplement_2).
    7. Baldus S, Doenst T, Pfister R, Gummert J, Kessler M, Boekstegers P, et al. Transcatheter Repair versus Mitral-Valve Surgery for Secondary Mitral Regurgitation. New England Journal of Medicine. 2024;391(19):1787-98.
    8. Mehra MR, Goldstein DJ, Cleveland JC, Cowger JA, Hall S, Salerno CT, et al. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial. JAMA. 2022;328(12):1233-42.
    9. Khush KK, Cherikh WS, Chambers DC, Goldfarb S, Hayes D, Jr., Kucheryavaya AY, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-fifth Adult Heart Transplantation Report—2018; Focus Theme: Multiorgan Transplantation. The Journal of Heart and Lung Transplantation. 2018;37(10):1155-68.
    10. Obadia J-F, Messika-Zeitoun D, Leurent G, Iung B, Bonnet G, Piriou N, et al. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation. New England Journal of Medicine. 2018;379(24):2297-306.
Acronyms and abbreviations

    BMI: Body mass index
    PCI: Percutaneous coronary intervention 
    LAD: Left anterior descending coronary artery
    LCx: Left circumflex coronary artery  
    ICD: Implantable cardioverter defibrillator
    EF: Ejection fraction
    PSAP: Pulmonary artery systolic pressure
    LVOT VTI: Left ventricle outflow tract velocity time integral 
    LVIDd I: Left ventricle internal diameter end-diastole indexed
    LVIDs I: Left ventricle internal diameter end-systole indexed 
    LVEDV I: Left ventricle end-diastolic volume indexed 
    TAPSE: Tricuspid annular plane systolic excursion
    EROA: Effective regurgitant orifice area 
    EDP: End diastolic pressure
    PCWP: Pulmonary capillary wedge pressure
    TPG: Transpulmonary gradient 
    PVR: Pulmonary vascular resistance
    SVR: Systemic vascular resistance 
    RER: Respiratory exchange ratio
    GDMT: Guideline directed medical therapy 

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