Abstract 4129273: Severe Mitral Regurgitation from Impella-associated Mitral Chordae Rupture with Successful Transcatheter Edge-to-edge Repair

Background: Limited data exists describing Impella-related mechanical mitral valve complications. Diagnosis and management can be challenging due to potential underestimation of mitral regurgitation severity from Impella and acute clinical deterioration upon removal. We present a case of successful mitral transcatheter edge-to-edge repair (TEER) for acute severe MR secondary to Impella-related mitral chordae rupture resulting in acute pulmonary edema post-Impella removal. Case Summary: A 37-year-old male smoker presented with chest pain complicated by cardiac arrest due to ventricular fibrillation. Spontaneous circulation could not be restored, requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Coronary angiography revealed total occlusion of the proximal left anterior descending artery, which was successfully stented. Transfemoral Impella CP was placed for left ventricular venting under fluoroscopy (Panel A) with TTE showing no complications. In the intensive care unit, the Impella was advanced under TTE guidance; its tip was found to be positioned deep at the base of the posteromedial pupillary muscle without suction alarms or ventricular arrhythmias on the following day (Panel B). Several days later, TTE revealed new eccentric MR with hyperdynamic left ventricular motion (Panel C). The patient remained hemodynamically stable after VA-ECMO decannulation with Impella at P4. Following Impella removal, he developed repeated flash pulmonary edema despite aggressive fluid removal attributed to acute severe MR secondary to a flail P3 leaflet with ruptured chordae tendineae confirmed by transesophageal echocardiography (Panel D). Given the patient's poor surgical candidacy with a STS score of 13.2%, the team proceeded with mitral TEER, successfully reducing MR severity from severe to mild with a single NT Mitraclip ® across the medial commissure (Panel E). His post-operative cardiac course was uneventful without recurrence of pulmonary edema. Discussion: Irreversible mechanical damage to the mitral valve apparatus caused by Impella placement and repositioning is a rare, potentially fatal complication requiring emergent intervention. Mitral TEER can be a viable salvage option for poor surgical candidates.