So, this is one…has been one of the most difficult cases that I have had. We'll see what you think, and I'm interested in hearing your opinion. So 76-year-old female with history of hypertension, atrial fibrillation, CKD, who has been known to have at least moderate to severe mitral regurgitation that has been called mixed for years with thick leaflets, tethering of the posterior leaflet, annular dilatation, and the chart mentioned in many notes MAC, but when you look at the CT, there's not really MAC. So, it's more…I think it was just degenerative changes that were seen on echo. So, anyway, no intervention was done in the past, so she presents to another institution with GI bleed and acute dyspnea, no chest pain, so just shortness of breath, GI bleed, and some notes in the ER mentioned a blood pressure as low as 40 over 30, so she was like literally dying in the ER. Heart rate was only 50 on May 5th. No murmur was noted, at least by ER notes, at this low level of blood pressure, so I don't know that they had known how severe the MR was at the time. Troponin was more than 5,000, likely 3.7, hemoglobin 8.2, but actively bleeding, hyaline out of 2.8, and a white count of 12.3. So she was resuscitated, atropine, dopamine, IV fluids, received blood transfusion. I can't remember at what point if she got some at the initial hospital stay or at our institution, but received blood as well. This was the EKG, so highly abnormal with some inferior…I'm sorry, I didn't mean to do that…some inferior ST elevations and very marked posterior changes as well, so mostly like inferior-posterior STEMI that was not acted upon very rapidly because of the active GI bleed. So that generated a lot of discussions and generated delays, and at some point, she gets transferred to our institution, but after the window of opportunity for primary PCI. So she undergoes a coronary angiogram, and not surprising, she's found to have 3-vasocAV with a culprit in a dominant right coronary, also lesions in the LAD and the left circumflex, but the culprit was thought to be distal right, as you can see, and there was already a little bit of faint collateral on the left system, but late presentation and was thought to be too late for primary PCI. And with the ongoing GI bleed, the team did not do primary PCI, of course. So this is a TTE. Prior to this admission, the EF was normal. So now 37% with inferior and posterior Wal-Mart…Wal-Mart Usher neuronalities with severe mitral regurgitation and an RVSP of 78, so you see a lot of MR there on the left, and on the right, you can see the short axis. It's a very wide jet of MR, so almost the entire line of coaptation. So a balloon pump is placed in the CATLA once they found the coronary anatomy that I mentioned to you. Cardiac surgery consult is requested for CAVG and mitral valve intervention and was considered to be too high risk with an STS score for CAVG and repair of 46.8 and for CAVG and replacement of the mitral valve of 56%. So they obtained three different surgical opinions, and they all three said this is prohibitive surgical risk, and now they come to us for a consultation for an urgent tear, and I must have been on call that day, I guess. That's why I was in a queue. And basically, like, we're on our own, so what do we do? So first of all, the first thing I did is, okay, let's look at the TEE, and many things that you want to know. Is this clippable, as we used to say, or is this anatomy favorable for tears, we should be saying. You know, do we have enough leaflet length to grasp how many clips? What is the valve area? So valve area is 7.1, but as you can see, it's a very wide jet of MR that was described in at least four different separate jets. I don't have all the images, but I selected a few that would give you the idea of the anatomy. As you can see there—oh, this is interesting. On the left, you see the amount of MR on balloon pump. I told you this patient was on balloon pump, so that's a one-to-one. And then our colleagues, while doing the TEE—this is on sedation—they put the balloon pump on standby and look at the amount of MR. So just something to keep in mind. When someone is holding a balloon pump, what you see may be artificially, you know, decreased just because of the ongoing support from the balloon pump. So they showed me this, and we said, okay, well, it's time to do something. Okay, to do something, what do we do? Do we do TIR? Do we consider TNVR? If the decision is TIR, how many devices? Where to start? Where to end? Or should we do PCI first? Remember, this is a late presentation in someone who has a GI bleed and receiving blood transfusions for GI bleed. Or do we do palliative care? And I will stop here, and we'll continue the discussion, I suppose, at the end, right? Okay.

mitral regurgitation

gastrointestinal bleed

coronary angiogram

high-risk procedure

treatment options