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An 81-year-old woman was referred for NSTEMI complicated by cardiogenic shock. Urgent invasive assessment revealed a subtotal left anterior descending artery (LAD) stenosis, severe aortic stenosis (mean gradient 60 mmHg, aortic valve area 0.5 cm2), decreased left ventricular (LV) function [left ventricular ejection fraction (LVEF) 49%], grade 3+ mitral regurgitation (MR), and severe pulmonary hypertension. In view of her critical situation, acute LAD–percutaneous coronary intervention and aortic valvuloplasty were performed with subsequent marked clinical improvement. Yet, she remained in NYHA class III. Given her critical condition, the likelihood of double valve operation and high predicted 30-day mortality (log EuroSCORE 74%, STS 30%), there was interdisciplinary consensus for catheter-based strategy, primarily treating the aortic stenosis possibly improving functional MR. Three weeks after the acute event, she underwent trans-femoral aortic valve implantation. However, despite an excellent technical result, LVEF and MR did not improve and she required 3 weeks ICU with intravenous catecholamines and diuretics administration.  As severe MR and severe pulmonary hypertension persisted, we opted for percutaneous mitral valve repair (Figure). One MitraClip® was successfully implanted between segment A2 and P2 with an MR reduction to grade 1+ and a drop in mean left atrial pressure from 31 to 19 mmHg.

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Cardiovascular Flashlights
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