What is the management of severe aortic stenosis in the Intensive Care Unit (ICU)?

ICU Management of Severe Aortic Stenosis

Balloon aortic valvuloplasty (BAV) is recommended as a bridge to definitive treatment in critically ill patients with severe aortic stenosis presenting with cardiogenic shock. 1

Initial Assessment and Stabilization

• Echocardiography is essential for diagnosis and assessment of aortic stenosis severity in critically ill patients, with transthoracic echocardiography (TTE) being the cornerstone of evaluation 1, 2
• Severe aortic stenosis is defined by an aortic valve area less than 1.0 cm², mean pressure gradient greater than 40 mmHg, and peak velocity greater than 4 m/s 2
• In low cardiac output states, diagnosis may be challenging but valve area calculation is essential rather than relying solely on transvalvular gradients 1
• For 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

Hemodynamic Management

• Careful fluid management is critical as patients with severe aortic stenosis are preload-dependent due to fixed obstruction to left ventricular outflow 3
• Avoid over-diuresis as it can lead to dangerous hemodynamic compromise; if it occurs, administer isotonic crystalloids in small boluses (250-500 mL) with frequent reassessment 3
• Maintain heart rate control as both bradycardia and tachycardia can lead to clinical decompensation 2
• Target systolic blood pressure between 100-120 mmHg in acute settings 2
• Beta-blockers are preferred agents for blood pressure control due to their ability to reduce the force of left ventricular ejection 2

Inotropic Support

• Important warning: Dobutamine should be used with caution in severe aortic stenosis as it may be ineffective or potentially harmful due to increasing outflow obstruction 4
• Dobutamine is contraindicated in cases of marked mechanical obstruction such as severe valvular aortic stenosis according to FDA labeling 4
• Similarly, milrinone should not be used in patients with severe obstructive aortic valvular disease in lieu of surgical relief of the obstruction 5
• When inotropic support is necessary, careful hemodynamic monitoring is essential, including pulmonary wedge pressure and cardiac output whenever possible 4

Definitive Treatment Options

• Balloon aortic valvuloplasty (BAV) is recommended as a bridge to definitive treatment in critically ill patients with cardiogenic shock 1
• After stabilization with BAV, patients should be evaluated for definitive treatment with either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) 1
• The decision between TAVI and SAVR should be made by a Heart Team based on surgical risk assessment 1, 2
• TAVI is recommended over SAVR for high or extreme-risk patients due to porcelain aorta, hostile chest anatomy, multiple comorbidities, frailty, or oxygen-dependent lung disease 1
• SAVR remains appropriate for patients with low surgical risk, younger age, no contraindications to surgery, or long life expectancy 1, 6

Special Considerations

• For patients with reduced ejection fraction (<50%) and severe aortic stenosis, aortic valve replacement (AVR) is appropriate and medical management alone is rarely appropriate 7
• Medical management alone is rarely appropriate for symptomatic patients with severe aortic stenosis, regardless of surgical risk 1
• 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
• If non-cardiac surgery is required in a patient with severe aortic stenosis, careful hemodynamic monitoring is essential 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
• Monitor vital signs closely, particularly blood pressure, as patients with severe aortic stenosis are susceptible to hypotension when preload is reduced 3
• Consider central venous pressure monitoring or echocardiography to guide fluid resuscitation in hemodynamically unstable patients 3

Pitfalls to Avoid

• Delaying intervention in symptomatic patients with severe aortic stenosis significantly increases mortality risk 1
• Do not rely solely on transvalvular gradients for diagnosis in low-flow states; valve area calculation is essential 1
• Recognize that even modest regurgitation that develops acutely may cause severe pulmonary congestion and systemic hypotension in critically ill patients 1
• Avoid excessive diuresis which can lead to dangerous hemodynamic compromise 3
• Do not use vasodilators aggressively as they can precipitate hypotension in patients with severe aortic stenosis 2