A male patient, 87 year-old, presented with chronic heart failure with reduced ejection fraction. He had a history of percutaneous coronary intervention, atrial fibrillation and implantation of left atrial appendage occluder, chronic kidney disease and chronic limb ischemia. He was treated with optimal medical therapy for heart failure; but, nevertheless, he still experienced impaired exercise tolerance. Blood pressure and heart rate was well controlled at 100/60 mmHg and 60-80 bpm.

The echocardiogram revealed a dilated left ventricle (LV) with end-systolic diameter of 60 mm (end-diastolic diameter of 70 mm) and dilated left atrium (LA) of 64 mm. The LV end-systolic volume of 111 mL. The LV systolic function was severely reduced (LV ejection fraction 23%), with akinetic LV apex and hypokinetic inferior wall. There was a severe mitral regurgitation (MR) due to annular dilatation and tethering of posterior leaflet. Other valves were normal.

Transcutaneous edge-to-edge mitral repair was done with placement of one MitraClip (Abbott) XTW at A2-P2 scallops. This resulted in trivial MR and disappearance of pulmonary vein systolic reversal with acceptable trans-mitral gradient of 3.5 mmHg. Unfortunately, he developed acute LV afterload mismatch which manifested as lung edema and shock 24 hour after his procedure. Systemic vascular resistance rose to 2729 dyn/s/cm-5. The blood pressure was dropped to 50 mmHg. He was medically managed with inotropic support and diuretics; without intra-aortic balloon pump therapy. He subsequently fully recovered and was discharged after a few days.

Percutaneous mitral repair in patients with very poor function is a less invasive and potentially safer alternative to open surgery, but acute LV afterload mismatch may occur. This requires prompt diagnosis and management for a successful outcome.