A 79-year-old woman with a past medical history of dementia, frailty, low body mass index (20.6 kg/m 2 ), thrombocytopenia, and atrial fibrillation, presented with cardiogenic shock. She was intubated for acute hypoxic respiratory failure, initiated on inotropic support, and an intra-aortic balloon pump (IABP) was placed for hemodynamic support. Transesophageal echocardiogram (TEE) demonstrated severe mitral regurgitation (MR) due to a wide flail segment of the P2 scallop (A–C). The left ventricular ejection fraction (LVEF) was preserved at 65%, and there was moderate right ventricular dysfunction. Left heart catheterization demonstrated mild nonobstructive coronary artery disease. Right heart catheterization, performed with support from vasopressors and the IABP, showed pulmonary artery pressures of 31/19 mm Hg, pulmonary artery capillary wedge pressure of 15 mm Hg, cardiac output (CO) of 2.49 L/min, and a cardiac index of 1.61 L/min per m 2 . She was deemed to be at prohibitively high risk for surgery, and thus underwent percutaneous mitral valve (MV) repair with the MitraClip system (Abbott Vascular, Santa Clara, CA). Via the traditional transseptal approach, two MitraClips were placed under TEE guidance, reducing the MR to trace-to-mild (D–F). The final mean MV gradient was 6 mm Hg. The patient was extubated immediately after the procedure. On postoperative day (POD) 1, the CO had increased to 3.6 L/min, and no inotropes were required. The IABP was subsequently removed. Four hours after IABP removal, the patient was noted to be restless and delirious, with cool extremities on exam. Transthoracic echocardiogram demonstrated an LVEF of 15% to 20%, global LV hypokinesis, moderate right ventricle (RV) dysfunction, and mild MR. An IABP was placed and epinephrine and milrinone were initiated, with suspicion for acute afterload mismatch. The LVEF improved to 45% on POD 8, and the IABP and epinephrine were discontinued. On POD 12, the LVEF was noted to be 60%, and milrinone was discontinued. The patient was discharged to a rehabilitation center and eventually returned home. At 6-month follow-up, the echocardiogram showed an LVEF of 65%, normal RV function, and mild MR.
