What is the appropriate inotrope to start in a patient with severe mitral regurgitation (MR) and severe aortic regurgitation (AR), low ejection fraction (31%), and severe hypotension (blood pressure 65/30 mmHg)?

From the Guidelines

For a patient with low ejection fraction (31%), severe mitral and aortic regurgitation, and hypotension (BP 65/30), I would recommend starting dobutamine at 2.5-5 mcg/kg/min, titrating up to 20 mcg/kg/min as needed, as it provides positive inotropic support to improve cardiac output while causing less peripheral vasoconstriction than other agents, which is beneficial in valvular regurgitation 1. This approach is supported by the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure, which suggest that inotropic agents, such as dobutamine, may be considered in patients with hypotension (systolic blood pressure <85 mmHg) and/or hypoperfusion to increase cardiac output, increase blood pressure, and improve peripheral perfusion 1. Some key points to consider in the management of this patient include:

• The need for careful fluid management to avoid volume overload, which could worsen congestion, while ensuring adequate preload 1.
• The importance of continuous hemodynamic monitoring, including arterial line and consideration of pulmonary artery catheterization, to guide therapy in this critically ill patient 1.
• The potential need for urgent cardiology consultation for possible mechanical circulatory support and surgical evaluation, as inotropes are only a temporary bridge 1.
• The consideration of adding norepinephrine starting at 0.01-0.1 mcg/kg/min to maintain mean arterial pressure above 65 mmHg if blood pressure remains critically low despite dobutamine, while avoiding pure vasopressors alone as they may worsen regurgitation by increasing afterload 1.

From the FDA Drug Label

Dobutamine Injection, USP is indicated when parenteral therapy is necessary for inotropic support in the short-term treatment of patients with cardiac decompensation due to depressed contractility resulting either from organic heart disease or from cardiac surgical procedures The patient has a low ejection fraction of 31% with severe MR and severe AR disease, and a blood pressure of 65/30, indicating cardiogenic shock.

• Dobutamine may be considered for inotropic support in this patient, as it is indicated for short-term treatment of cardiac decompensation due to depressed contractility.
• However, it is essential to monitor the patient closely, as dobutamine can increase the risk of arrhythmias and may not be effective in the long-term treatment of congestive heart failure 2.
• Milrinone may not be the best choice in this scenario, as it is not recommended for patients with severe obstructive aortic or pulmonic valvular disease, and the patient's severe AR disease may be a concern 3.

From the Research

Patient Management

The patient has a low ejection fraction of 31% with severe mitral regurgitation (MR) and severe aortic regurgitation (AR), and is currently hypotensive with a blood pressure of 65/30 mmHg.

Inotrope Selection

• The choice of inotrope should be guided by the patient's hemodynamic profile and underlying condition.
• Studies have shown that the combination of norepinephrine and dobutamine can be effective in improving cardiac index and reducing lactate levels in patients with cardiogenic shock 4.
• Norepinephrine can help increase blood pressure, while dobutamine can improve cardiac contractility and reduce pulmonary vascular resistance.
• However, the use of epinephrine may be associated with increased heart rate, arrhythmias, and lactic acidosis 4.

Treatment Approach

• Consider starting with a combination of norepinephrine and dobutamine to improve blood pressure and cardiac contractility.
• Monitor the patient's hemodynamic response closely, including blood pressure, cardiac output, and lactate levels.
• Adjust the dosage of norepinephrine and dobutamine as needed to achieve optimal hemodynamic goals.
• Consider the use of central venous pressure (CVP) and pressure difference between usual mean arterial pressure (MAP) and MAP (dMAP) to guide adjustments in norepinephrine dosage 5.

Personalized Approach

• A personalized approach to the early start of norepinephrine in septic shock patients has been suggested, taking into account the patient's condition, including the depth and duration of hypotension 6.
• Early administration of norepinephrine may be considered in patients with profound hypotension, low diastolic blood pressure, or high diastolic shock index.
• However, the decision to start norepinephrine early should be individualized and based on the patient's specific clinical profile.