How to manage a patient with severe aortic stenosis, reduced ejection fraction, and hypotension?

From the Guidelines

The patient with severe aortic stenosis, reduced ejection fraction, and hypotension should undergo urgent aortic valve replacement, either surgical (SAVR) or transcatheter (TAVR), after initial stabilization. For immediate management, cautious volume optimization is essential—administer small fluid boluses (250-500 mL) if the patient appears hypovolemic, while monitoring for pulmonary congestion. Inotropic support with dobutamine (starting at 2-5 mcg/kg/min, titrating up to 20 mcg/kg/min as needed) can improve cardiac output by enhancing contractility without significantly increasing heart rate or decreasing systemic vascular resistance 1. Vasopressors like norepinephrine (starting at 0.01-0.1 mcg/kg/min) may be needed to maintain coronary perfusion pressure. Avoid vasodilators, negative inotropes (beta-blockers, calcium channel blockers), and diuretics if possible as they can worsen hypotension. Maintain normal sinus rhythm, as these patients are dependent on atrial contraction for ventricular filling. If heart failure symptoms are present, cautious use of low-dose diuretics may be necessary. This approach aims to optimize preload, maintain afterload, and support contractility while arranging for definitive valve replacement, as medical management alone is insufficient for severe aortic stenosis with compromised left ventricular function and hypotension 1.

Some key considerations in the management of such patients include:

• The importance of differentiating between true severe aortic stenosis and pseudo-aortic stenosis, especially in patients with low-flow, low-gradient aortic stenosis, using low-dose dobutamine stress echocardiography 1.
• The role of transcatheter aortic valve replacement (TAVR) as a viable option for patients who are at high risk for surgical aortic valve replacement (SAVR) or have contraindications to surgery 1.
• The need for careful perioperative management in patients with severe aortic stenosis undergoing noncardiac surgery, including optimization of hemodynamics and consideration of aortic valve replacement before noncardiac surgery if symptomatic 1.

Overall, the management of patients with severe aortic stenosis, reduced ejection fraction, and hypotension requires a multidisciplinary approach, careful hemodynamic optimization, and timely intervention to improve outcomes.

From the FDA Drug Label

Milrinone lactate should not be used in patients with severe obstructive aortic or pulmonic valvular disease in lieu of surgical relief of the obstruction. No improvement may be observed in the presence of marked mechanical obstruction, such as severe valvular aortic stenosis

The patient has severe aortic stenosis, reduced ejection fraction, and hypotension. Severe aortic stenosis is a contraindication for the use of milrinone and dobutamine, as these medications may worsen the obstruction.

• The patient's condition requires careful management to avoid exacerbating the aortic stenosis.
• Surgical relief of the obstruction may be necessary to improve the patient's condition.
• In the meantime, cautious fluid resuscitation and hemodynamic monitoring should be continued to support the patient's blood pressure and cardiac output.
• Lisinopril is also not recommended in this scenario due to the risk of symptomatic hypotension, particularly in patients with severe aortic stenosis or hypertrophic cardiomyopathy 2.
• The patient's renal function and electrolyte levels should be closely monitored due to the risk of acute renal failure and hyperkalemia associated with ACE inhibitors 2.

From the Research

Patient Management

To manage a patient with severe aortic stenosis, reduced ejection fraction, and hypotension, the following steps can be considered:

• Fluid resuscitation to improve blood pressure and perfusion, as seen in the initial treatment of the patient 3
• Evaluation of the patient's condition to determine the best course of treatment, considering the severity of aortic stenosis and left ventricular dysfunction
• Consideration of antihypertensive treatment, which may be safe and beneficial in reducing the progression of left ventricular pressure overload and valvular aortic stenosis, although no definitive treatment guidelines exist 4
• Potential use of β-blockers, which may be safe and beneficial, although their use has been generally avoided in patients with severe aortic stenosis due to concerns about inducing left ventricular dysfunction and hemodynamic compromise 4
• Consideration of renin-angiotensin system (RAS) inhibition, which may be beneficial in retarding the progression of valvular stenosis and left ventricle remodeling 4

Treatment Options

Treatment options for the patient may include:

• Aortic valve replacement (AVR), which is generally recommended for patients with severe symptomatic aortic stenosis, although the operative risk is higher in patients with reduced ejection fraction 3
• Transcatheter aortic valve replacement (TAVR), which may be beneficial for patients with moderate aortic stenosis and heart failure with reduced ejection fraction, although more research is needed to determine the ideal timing and patient selection for this procedure 5
• Medical management, including antihypertensive treatment and RAS inhibition, to reduce the progression of left ventricular pressure overload and valvular aortic stenosis 4

Hemodynamic Considerations

Hemodynamic changes during aortic valve surgery should be carefully monitored, as patients with severe aortic stenosis are at increased risk of hypotension and hypoperfusion 6

• Dobutamine infusion may increase cardiac index, but its effect on stroke volume index is highly variable and associated with baseline left ventricular ejection fraction
• Fluid bolus may increase cardiac index, stroke volume index, and pulmonary capillary wedge pressure, although the increase in pulmonary capillary wedge pressure may be more pronounced in patients with a larger left atrial volume index 6