HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
60-year-old patient with a history of hypertension, dyslipidaemia, COPD, left temporoparietal ischaemic stroke with no subsequent sequelae, dilated heart disease of ischaemic origin, which debuted in the form of inferolateral AMI 20 years earlier, with subsequent echocardiogram showing severely dilated left ventricle with severe ventricular dysfunction (LVEF 20%) secondary to inferoposterior akinesia and hypokinesia of the remaining segments, with mild mitral insufficiency, without other significant valvulopathies. It was decided to implant an ICD as primary prevention and CRT, with improvement in systolic function (LVEF 35%).
The patient consulted the emergency department for dyspnoea of 4 days' duration, accompanied by cough and fever. Haemodynamically, BP 96/65 mmHg, febrile at 38°C, 02 saturation 92 % with KVM 24 %. Physical examination revealed abundant rhonchi and wheezing predominantly in right fields, with bibasal crackles, systolic murmur predominantly in mitral focus, bimalleolar oedema and jugular ingurgitation.
Arterial blood gas with Fi02 of 24 % showed pH 7.476, pC02 34 mmHg, p02 59 mmHg, HCO3 24.5 mmol/L. CBC with minimal elevation of acute phase reactants (CRP 1.74 mg/dl) and leukocytosis 11910/L with neutrophilia 81 %, slightly altered renal function (creatinine 1.32 mg/dl and GFR 54 ml/min), correct ionogram.
Chest X-ray with signs of vascular redistribution as well as a consolidating image in the right middle lobe, suggestive of pneumonic process.
ECG in sinus rhythm 95 bpm, with ventricular rhythm stimulated by CRT.
The patient was diagnosed with respiratory infection and decompensation of heart failure in a patient with chronic ischaemic heart disease in the dilated phase. Diuretic treatment and antibiotic therapy were started.

COMPLEMENTARY TESTS
Chest X-ray: signs of vascular redistribution as well as a consolidating image in the right middle lobe, suggestive of a pneumonic process.
ECG: sinus rhythm 95lpm, with ventricular rhythm stimulated by CRT.
Echocardiogram on admission: LVEF 35-40 %. Severe mitral insufficiency with restriction of the posterior leaflet and probable prolapse of the anterior leaflet. Severe dilatation of left ventricle slightly-moderately hypertrophic, with moderate reduction of motility due to inferolateral and inferior akinesia. LVEF 35-40 %. Moderate left atrial dilatation. Right ventricle with preserved motility. Device lead in right cavities. Mild tricuspid insufficiency that allows estimating PAPs 46 mmHg. No pericardial effusion.
Transesophageal echocardiogram: severe mitral insufficiency secondary to restrictive movement of the posterior leaflet and prolapse of the anterior leaflet at the level of A2 with an image of chordal rupture.
Coronary angiography: right dominance. Truncus description: lesion 20% distal.
Description of the anterior descending artery: long development, very calcified. Lesion 50 % to the middle tract. Circumflex description: very calcified. Lesion 30% proximal.
Right coronary description: occluded proximally (since 2002). Bad distal vessel.
Echocardiogram during implantation: implantation of two MitraClip (x2) at level A2 P2 segments of the mitral valve. Well positioned devices with slight residual leak (grade I/IV).
Fluoroscopy: implantation of 2 MitraClip.

EVOLUTION
During hospitalisation the patient shows improvement from the infectious point of view.
However, his heart failure worsened and he went into cardiogenic shock, requiring non-invasive mechanical ventilation and inotropic support. A transthoracic echocardiogram showed severe mitral insufficiency, with restriction of the posterior leaflet and possible prolapse of the anterior leaflet. To better visualise the mechanism of mitral insufficiency, a transesophageal echocardiogram was performed which confirmed severe mitral insufficiency secondary to restrictive movement of the posterior leaflet and prolapse of the anterior leaflet at the level of A2 with an image of chordal rupture. Coronary angiography showed moderate lesions of the left coronary artery with chronic occlusion of the right coronary artery, already present in previous studies.
The patient had a torpid clinical evolution, with cardiogenic shock refractory to medical treatment, requiring orotracheal intubation, invasive mechanical ventilation and implantation of aortic balloon counterpulsation.
The case was assessed jointly with the Cardiac Surgery and Haemodynamics team and, given the high surgical risk, MitraClip implantation was decided. The patient arrived in the haemodynamics room with inotropic support with dobutamine, aortic balloon counterpulsation, orotracheal intubation and mechanical ventilation. The procedure was guided by transesophageal echocardiography and scopy. Given the difficulty of the case, a strategy with at least 2 clips was considered from the beginning. The first clip was successfully implanted after multiple attempts, and a second, more lateral clip was subsequently implanted, thereby reducing the MR from grade 4 to 1.
Subsequently, the patient had a good clinical evolution, being able to remove the counterpulsation balloon, ionotropic and ventilatory support, and was discharged haemodynamically stable with no signs of heart failure. Echocardiogram at discharge showed an estimated EF of 25-30%, MitraClip implantation (x2) at segment A2 P2 level of the mitral valve with well-positioned devices with mild residual leak (grade I/IV).
Six months after discharge, the patient persists in NYHA functional class I-II, with no cardiac decompensation.

DIAGNOSIS
Community-acquired right middle lobe pneumonia.
Heart failure with biventricular dysfunction.
Cardiogenic shock.
Severe mitral insufficiency secondary to restrictive movement of the posterior leaflet and prolapse of the anterior leaflet at A2 level with chordal rupture image.
Chronic ischaemic heart disease in dilated phase.
