Emergency mitral valve transcatheter edge-to-edge repair in cardiogenic shock due to papillary muscle rupture.

UNLABELLED: Cardiogenic shock secondary to papillary muscle rupture carries high mortality and often precludes surgical repair. We present a case of acute mitral regurgitation following myocardial infarction managed with emergent transcatheter edge-to-edge repair (TEER) under combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and transvalvular assist device (Impella, Abiomed, Danvers, MA, USA) support. Real-time echocardiographic guidance required transient VA-ECMO flow reduction to optimize right atrial visualization and Impella adjustment to prevent device interference. Sequential clip deployment achieved significant mitral regurgitation reduction and hemodynamic improvement. This case highlights the feasibility, imaging challenges, and multidisciplinary coordination required for successful TEER in refractory cardiogenic shock.

LEARNING OBJECTIVE: We illustrate the feasibility and technical nuances of performing transcatheter edge-to-edge mitral valve repair in cardiogenic shock due to papillary muscle rupture under combined veno-arterial extracorporeal membrane oxygenation and Impella support. This case emphasizes the critical role of real-time multimodality echocardiographic guidance, hemodynamic optimization through temporary device flow adjustments, and coordinated multidisciplinary decision-making in achieving procedural success when conventional surgical repair is not feasible.