What is the management for critically ill patients with severe aortic stenosis?

Management of Critical Aortic Stenosis in Critically Ill Patients

For critically ill patients with severe aortic stenosis, balloon aortic valvuloplasty (BAV) should be used as a bridge to definitive treatment with either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in hemodynamically unstable patients. 1

Initial Assessment and Stabilization

• Echocardiography is the cornerstone for diagnosis and assessment of aortic stenosis severity, even in critically ill patients 1, 2
• In low cardiac output states, diagnosis may be challenging but transthoracic echocardiography (TTE) findings are typically characteristic 1
• Initial management should focus on restoring adequate preload and maintaining normal heart rate, as both bradycardia and tachycardia can lead to clinical decompensation 3
• For hypotensive patients, vasopressors should be used at the lowest effective dose to maintain adequate perfusion 3

Management Algorithm for Critical Aortic Stenosis

For Hemodynamically Unstable Patients (Cardiogenic Shock)

• Balloon aortic valvuloplasty (BAV) is recommended as a bridge to definitive treatment in critically ill patients with cardiogenic shock 1
• Echocardiography should be used to assess suitability for BAV in patients with critical aortic stenosis and cardiogenic shock 1
• After stabilization with BAV, patients should be evaluated for definitive treatment with either TAVI or SAVR based on surgical risk assessment 1, 2

For Symptomatic Patients Requiring Urgent Non-Cardiac Surgery

• BAV can be considered as a bridge to surgery for patients with symptomatic severe aortic stenosis who require urgent major non-cardiac surgery 1
• For patients with critical aortic stenosis and hip fracture, a multidisciplinary approach is essential, with options including:
  • Hip surgery under careful hemodynamic monitoring followed by valve replacement
  • Preoperative BAV to allow hip surgery followed by valve replacement
  • Preoperative minimalist TAVI for selected patients 4

Definitive Treatment Selection

• The decision between TAVI and SAVR should be made by a Heart Team based on surgical risk assessment 1, 2
• TAVI is preferred over surgical AVR for high or extreme-risk patients due to:
  • Porcelain aorta or hostile chest anatomy
  • Multiple comorbidities
  • Frailty or disability
  • Oxygen-dependent lung disease 1, 2
• SAVR remains appropriate for patients with:
  • Low surgical risk (STS-PROM <3%)
  • Younger age (<65-75 years)
  • No contraindications to surgery
  • Long life expectancy (>10 years) 1, 2

Special Considerations

• In patients with low-flow, low-gradient severe aortic stenosis with reduced ejection fraction, dobutamine stress echocardiography should be performed to confirm true stenosis severity 1, 2
• Medical management alone is rarely appropriate for symptomatic patients with severe aortic stenosis, regardless of surgical risk 2
• For patients with prohibitive surgical risk and life expectancy <1 year or moderate-to-severe dementia, palliative care with medical management may be considered 1, 2

Monitoring and Follow-up

• After BAV as a bridge procedure, patients should be closely monitored for restenosis and prepared for definitive treatment 1
• Careful hemodynamic monitoring is essential during and after any intervention in critically ill patients with severe aortic stenosis 1, 2

Pitfalls to Avoid

• Delaying intervention in symptomatic patients with severe aortic stenosis significantly increases mortality risk 1
• Avoid hypotension in patients with critical aortic stenosis as it can precipitate cardiovascular collapse 3
• Do not rely solely on transvalvular gradients for diagnosis in low-flow states; valve area calculation is essential 1, 2
• Recognize that even modest regurgitation that develops acutely may cause severe pulmonary congestion and systemic hypotension in critically ill patients 1