HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
76-year-old man, retired miner and ex-smoker of half a packet a day, with added CVRFs such as hypertension, dyslipidaemia and hyperuricaemia. Stroke of ischaemic origin 6 years ago without sequelae, of probable atherothrombotic as well as cardioembolic aetiology due to critical stenosis of the right carotid artery which required bypass and now permanent AF not previously diagnosed and for which he had to start oral anticoagulation therapy. Since then, he has been admitted several times for episodes of upper and lower gastrointestinal bleeding of very poor control. On regular treatment with furosemide, bisoprolol, ramipril, tamsulosin, allopurinol and sintrom. Admitted to a regional hospital for cough, whitish expectoration and progressive dyspnoea of a week's evolution until becoming minimal effort associated with the appearance of oedema in the lower limbs.

On arrival at the Emergency Department, he presented with a BP of 126/70 and a temperature of 36.9°C. Eupneic at 45o with O2 at 2 bpm. Cardiopulmonary auscultation revealed arrhythmic heart sounds without murmurs at 76 bpm and hypoventilation in the left lung base. He also had oedema with fovea in the lower limbs, up to the middle third.

COMPLEMENTARY TESTS
CBC: Hb 11.5, Ht 36%, leukocytes 4,000 (normal formula), platelets 103,000, PT 12.9%, INR 5.5, renal, hepatic and ion profile normal. ABG: pH 7.47, pO2 56, pCO2 34, HCO3 25, SatO2 91 %. Chest X-ray: global cardiomegaly, signs of vascular redistribution, fluid in cystole, left pleural effusion. ECG: AF at 75 bpm, narrow QRS at 0o, meets Cornell and Sokolov criteria for LVH and signs of LV overload. TTE: dilated LV (Dtd 58 mm) with mild concentric hypertrophy and moderate left ventricular dysfunction at the expense of generalised hypokinesia. Elevation of filling pressures. Mildly dilated RV with mild ventricular dysfunction. Dilated LA (31 cm2). Significant moderate bicommissural MR III/IV at the expense of at least two jets; dilatation of Carpentier's type I annulus. Moderate TR III/IV. Severe PHT at rest. Pericardial effusion without signs of haemodynamic compromise. Haemodynamic study: severely dilated LV (indexed VTD 116 ml/m2), with severe systolic dysfunction (LVEF 30%) at the expense of diffuse hypokinesia. Severe MI. Mild PHT (PAPs 42 mmHg, PAPm 25 mmHg, PCPm 16 mmHg). Coronary arteries with calcifications without angiographically significant stenosis.

EVOLUTION
The patient was treated with diuretics, resolving the episode of decompensated heart failure and in view of the findings, now haemodynamically stable, he was transferred to our centre for left and right heart catheterisation with the results described above.

The patient was referred to the monographic consultation for structural heart disease at our centre where he was profiled as a candidate for MitraClip device implantation and concomitant closure of the left atrial appendage given his high haemorrhagic (HAS-BLED = 5) and thromboembolic (CHADS-VASc = 7) risk, and the intervention was scheduled for one month later, following a favourable preoperative assessment (ASA III). Throughout this period the patient persisted in functional class II, and continued with two-pillow orthopnoea and episodes of paroxysmal nocturnal dyspnoea. The MitraClip device was implanted in A3P3 position, achieving an improvement in cardiac output and a reduction in mitral insufficiency from 4+ to 0.5+. Subsequently, in the same procedure, a Watchman device was implanted to close the 27 mm left atrial appendage with adequate sealing. During the intervention, the patient presented a fall in AF with low TAS figures and required electrical cardioversion, leaving in sinus rhythm. He was admitted to the Coronary Care Unit and a control TEE was performed which showed correct placement of the device with a slight residual MR due to two lateral jets to the clip and with an average gradient of 2 mmHg, slight TR, PAPs of 35 mmHg and LVEF in the lower limits of normality. During his stay in the unit there were no incidents, so he was transferred to the ward and three days after the operation he was discharged, and it was decided to suspend oral anticoagulation with sintrom and to start treatment with apixaban 2.5 mg/12 hours. Currently, the patient continues to attend the structural heart disease consultation for device control, presenting a clear improvement in his symptoms and his functional class (NYHA I) and not having presented any more episodes of upper or lower gastrointestinal haemorrhage.

DIAGNOSIS
Dilated cardiomyopathy with biventricular dysfunction of non-ischaemic aetiology.
ACC/AHA stage C decompensated heart failure in NYHA functional class II.
Functional Mitral Insufficiency III/IV
Severe PHT.
MitraClip device implantation.
Percutaneous closure of the left atrial appendage.
