Comprehensive Diagnostic and Therapeutic Algorithm for Managing Cardiogenic Shock in Valvular Heart Disease

Management of cardiogenic shock associated with valvular heart disease (VHD).

Triggers of Cardiogenic Shock

• Acute events:
  • Acute myocardial infarction
  • Hypertensive crisis
  • Endocarditis
• Pre-existing stable VHD:
  • Native aortic stenosis
  • Native mitral stenosis
  • Structural bio-prosthetic valve degeneration
• Acute onset of severe VHD:
  • Primary mitral regurgitation (e.g., chordal rupture, papillary muscle rupture)
  • Ischemic mitral regurgitation
  • Aortic regurgitation (e.g., Type A aortic dissection)
  • Structural bio-prosthetic valve degeneration (e.g., leaflet tear, valve thrombosis)

Initial Management:

• “Check for Futility” Phase:
  • Manage triggers (e.g., blood transfusion, electrical cardioversion)
  • Administer inotropes and/or vasopressors
  • Perform ancillary procedures (e.g., PCI, anticoagulation, fibrinolysis for valve thrombosis)
  • Support organ function (e.g., mechanical ventilation, renal replacement therapy)

Fast Re-Evaluation for Persistent Cardiogenic Shock:

• Conduct a heart team evaluation.
• Check for futility again.
• Consider:
  • Mechanical circulatory support
  • Multimodality imaging
  • Valve intervention as appropriate.

Valve-Specific Interventions:

Based on the type of VHD:

• Aortic Stenosis:
  • TAVI, balloon aortic valvuloplasty, or surgery.
• Aortic Regurgitation:
  • Surgical evaluation, TAVI in selected cases.
• Mitral Stenosis:
  • Percutaneous mitral balloon valvuloplasty or surgery in selected cases.
• Mitral Regurgitation:
  • Transcatheter edge-to-edge repair (TEER) or surgery.
• Bio-prosthetic Valve Failure:
  • Valve-in-valve procedures, transcatheter PVL occlusion, or redo surgery.
• Multiple Valve Disease:
  • Transcatheter or surgical approaches tailored to the pathology.