Treatment of Secondary Mitral Regurgitation: Opportunities and Unknowns
A 71-year-old-woman with a history of diabetes mellitus on insulin, coronary artery disease (s/p percutaneous coronary intervention), chronic kidney disease (stage III, eGFR = 30 mL/min/1.73 m2), and longstanding cardiomyopathy (S/P CRT-D implantation) presents for evaluation of progressive dizziness and shortness of breath.
In the home setting, her blood pressure was 70/50 mmHg. She was admitted to the hospital for further testing. A transthoracic echocardiogram showed a dilated left ventricle (LV) with LV diastolic dimension of 6.8 cm and systolic dimension of 6.0 cm, LV ejection fraction of 26%, and significant mitral regurgitation (MR). Her laboratory testing revealed an NT-ProBNP of 3542.0 pg/mL (increased). A transesophageal echocardiogram was performed to assess the severity of MR and showed the following:
- Markedly dilated and hypcontractile LV (ejection fraction ~18%) (Video 1A)
- LV non-compaction with marked/deep trabeculations of the apex (Video 1B)
- Markedly restricted leaflet motion with a slightly eccentric, posteriorly-directed jet along the entire coaptation line (Video 1C)
- A proximal isovelocity surface area (PISA) regurgitant area of 46 mm2 with regurgitant volume of 59 cc
- Quantitative Doppler regurgitant volume of 125 cc with regurgitant orifice area of 96 mm2 and regurgitant fraction of 76%, which was supported by the three-dimensional vena contracta area measurement (Video 1D)
- Systolic reversal of pulmonary vein inflow.
A right and left heart catheterization revealed RA=2 mmHg, RV=58/4 mmHg, PA=55/25/m34 mmHg, PCWP=24 mmHg, PA sat=52%, Fick CO=2.82 L/min, Fick CI=1.7 L/min/m2 (BSA = 1.58 m2). Left heart catheterization showed non-obstructive coronary artery disease with patent circumflex stent.
The patient refused consideration of destination left ventricular assist device given her limited home support and was placed on home intravenous milrinone, as well as her standard medications of Torsemide, Spironolactone. She did well for 2 weeks but presented again with progressive shortness of breath and multiple ICD shocks for ventricular tachycardia.
What is the best treatment option for the patient at this time?