Structural Heart Disease Emergencies

The various perioperative issues of structural heart diseases and cardiogenic shock

Up to 20 % of patients presenting with acute heart failure and cardiogenic shock have a structural etiology. Despite efforts in timely management, mortality rates remain alarmingly high, ranging from 50 % to 80 %. Surgical intervention is often the definitive treatment for structural heart disease; however, many patients are considered high risk or unsuitable candidates for such procedures. Consequently, there has been a paradigm shift towards the development of novel percutaneous management strategies and temporizing interventions. This article aims to provide a comprehensive review of the pathophysiology of valvular and structural heart conditions presenting in cardiogenic shock, focusing on the evolving landscape of mechanical circulatory support devices and other management modalities.

ICU management of cardiogenic shock before mechanical support

PURPOSE OF REVIEW

Treatment of cardiogenic shock remains largely driven by expert consensus due to limited evidence from randomized controlled trials. In this review, we aim to summarize the approach to the management of patients with cardiogenic shock in the ICU prior to mechanical circulatory support (MCS).

RECENT FINDINGS

Main topics covered in this article include diagnosis, monitoring, initial management and key aspects of pharmacological therapy in the ICU for patients with cardiogenic shock.

SUMMARY

Despite efforts to improve therapy, short-term mortality in patients with cardiogenic shock is still reaching 40-50%. Early recognition and treatment of cardiogenic shock are crucial, including early revascularization of the culprit lesion with possible staged revascularization in acute myocardial infarction (AMI)-CS. Optimal volume management and vasoactive drugs titrated to restore arterial pressure and perfusion are the cornerstone of cardiogenic shock therapy. The choice of vasoactive drugs depends on the underlying cause and phenotype of cardiogenic shock. Their use should be limited to the shortest duration and lowest possible dose. According to recent observational evidence, assessment of the complete hemodynamic profile with a pulmonary artery catheter (PAC) was associated with improved outcomes and should be considered early in patients not responding to initial therapy or with unclear shock. A multidisciplinary shock team should be involved early in order to identify potential candidates for temporary and/or durable MCS.

Prevalence of respiratory failure and use of mechanical ventilation in heart failure patients undergoing left atrial appendage occlusion device implantation

BACKGROUND

We sought to evaluate respiratory complications in heart failure patients undergoing left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation.

METHODS

Adult admissions (>18 years) undergoing LAAO during 2016-2020 were identified from the National Inpatient Sample. Heart failure (HF) was stratified into systolic (SHF) and diastolic heart failure (DHF) and were compared to those without HF. Outcomes of interested included acute respiratory failure, use of non-invasive and invasive mechanical ventilation, and in-hospital mortality.

RESULTS

Of 74,440 admissions for atrial fibrillation undergoing LAAO, SHF and DHF were noted in 8335 (11.2%) and 10,925 (14.7%), respectively. The SHF cohort was predominantly male (78%) whereas DHF cohort were female (53%). Compared to those without HF, presence of SHF (2.3% vs. 0.6%; adjusted odds ratio [OR] 1.61 [95% confidence interval {CI} 1.10-2.36]; p = 0.01) and DHF (2.8% vs. 0.6%; adjusted OR 2.20 [95% CI 1.58-3.06]; p < 0.001) were associated with higher rates of acute respiratory failure. SHF (1.7% vs. 0.6%; adjusted OR 1.70 [95% CI 1.07-2.71]; p = 0.02) group but not DHF (1.2% vs. 0.6%; adjusted OR 1.21 [95% CI 0.78-1.89]; p = 0.39) was associated with higher rates of non-invasive ventilation, whereas the DHF group (0.9% vs. 0.2%; adjusted OR 1.91 [95% CI 1.08-3.34]; p = 0.02) but not SHF (0.8% vs. 0.2%; adjusted OR 1.54 [95% CI 0.83-2.84]; p = 0.17) was associated with higher rates of invasive mechanical ventilation use. In-hospital mortality was comparable between cohorts.

CONCLUSION

Compared to those without HF, atrial fibrillation admissions with HF undergoing LAAO had higher rates of acute respiratory failure and mechanical ventilation rates without differences in in-hospital mortality.

Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery

Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.

Advances in the Management of Cardiogenic Shock

OBJECTIVES

To review a contemporary approach to the management of patients with cardiogenic shock (CS).

DATA SOURCES

We reviewed salient medical literature regarding CS.

STUDY SELECTION

We included professional society scientific statements and clinical studies examining outcomes in patients with CS, with a focus on randomized clinical trials.

DATA EXTRACTION

We extracted salient study results and scientific statement recommendations regarding the management of CS.

DATA SYNTHESIS

Professional society recommendations were integrated with evaluated studies.

CONCLUSIONS

CS results in short-term mortality exceeding 30% despite standard therapy. While acute myocardial infarction (AMI) has been the focus of most CS research, heart failure-related CS now predominates at many centers. CS can present with a wide spectrum of shock severity, including patients who are normotensive despite ongoing hypoperfusion. The Society for Cardiovascular Angiography and Intervention Shock Classification categorizes patients with or at risk of CS according to shock severity, which predicts mortality. The CS population includes a heterogeneous mix of phenotypes defined by ventricular function, hemodynamic profile, biomarkers, and other clinical variables. Integrating the shock severity and CS phenotype with nonmodifiable risk factors for mortality can guide clinical decision-making and prognostication. Identifying and treating the cause of CS is crucial for success, including early culprit vessel revascularization for AMI. Vasopressors and inotropes titrated to restore arterial pressure and perfusion are the cornerstone of initial medical therapy for CS. Temporary mechanical circulatory support (MCS) is indicated for appropriately selected patients as a bridge to recovery, decision, durable MCS, or heart transplant. Randomized controlled trials have not demonstrated better survival with the routine use of temporary MCS in patients with CS. Accordingly, a multidisciplinary team-based approach should be used to tailor the type of hemodynamic support to each individual CS patient's needs based on shock severity, phenotype, and exit strategy.

Establishing a Novel Diagnostic Framework Using Handheld Point-of-Care Focused-Echocardiography (HoPE) for Acute Left-Sided Cardiac Valve Emergencies: A Bayesian Approach for Emergency Physicians in Resource-Limited Settings

Acute severe cardiac valve emergencies, such as acute severe mitral regurgitation (AMR) and acute severe aortic regurgitation (AAR), present significant challenges in terms of diagnosis and management. Handheld point-of-care ultrasound devices have emerged as potentially pivotal tools in ensuring the prompt and accurate diagnosis of these left-sided valve emergencies by emergency physicians, particularly in resource-limited settings. Despite the increased utilisation of point-of-care ultrasound by emergency physicians for the management of patients in states of acute cardiorespiratory failure, current diagnostic protocols cannot perform sufficient quantitative assessments of the left-sided cardiac valves. This review elucidates and evaluates the diagnostic utility of handheld point-of-care focused-echocardiography (HoPE) in native AMR and AAR by reviewing the relevant literature and the use of clinical case examples from the Emergency Department at Port Shepstone Regional Hospital (PSRH-ED)-a rural, resource-limited hospital located in KwaZulu-Natal, South Africa. Combining the findings of the review and clinical case illustrations, this review proceeds to synthesise a novel, Bayesian-inspired, iterative diagnostic framework that integrates HoPE into the evaluation of patients with acute cardiorespiratory failure and suspected severe left-sided valve lesions.

Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology

Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.

Valvular Heart Disease Emergencies: A Comprehensive Review Focusing on the Initial Approach in the Emergency Department

Valvular heart disease (VHD) is an increasing health problem worldwide. Patients with VHD may experience several cardiovascular-related emergencies. The management of these patients is a challenge in the emergency department, especially when the previous heart condition is unknown. Specific recommendations for the initial management are currently poor. This integrative review proposes an evidence-based three-step approach from bedside VHD suspicion to the initial treatment of the emergencies. The first step is the suspicion of underlying valvular condition based on signs and symptoms. The second step comprises the attempt to confirm the diagnosis and assessment of VHD severity with complementary tests. Finally, the third step addresses the diagnosis and treatment options for heart failure, atrial fibrillation, valvular thrombosis, acute rheumatic fever, and infective endocarditis. In addition, several images of complementary tests and summary tables are provided for physician support.

The role of temporary mechanical circulatory support in de novo heart failure syndromes with cardiogenic shock: A contemporary review

Cardiogenic shock (CS) is a complex clinical syndrome with a high mortality rate. It can occur to due to multiple etiologies of cardiovascular disease and is phenotypically heterogeneous. Acute myocardial infarction-related CS (AMI-CS) has historically been the most prevalent cause, and thus, research and guidance have focused primarily on this. Recent data suggest that the burden of non-ischemic CS is increasing in the population of patents requiring intensive care admission. There is, however, a paucity of data and guidelines to inform the management of these patients who fall into two broad groups: those with existing heart failure and CS and those with no known history of heart failure who present with "de novo" CS. The use of temporary mechanical circulatory support (MCS) has expanded across all etiologies, despite its high cost, resource intensity, complication rates, and lack of high-quality outcome data. Herein, we discuss the currently available evidence on the role of MCS in the management of patients with de novo CS to include fulminant myocarditis, right ventricular (RV) failure, Takotsubo syndrome, post-partum cardiomyopathy, and CS due to valve lesions and other cardiomyopathies.

SKey Concepts Surrounding Cardiogenic Shock

Cardiogenic shock (CS) is the final common pathway of impaired cardiovascular performance that results in ineffective forward cardiac output producing clinical and biochemical signs of organ hypoperfusion. CS represents the most common cause of shock in the cardiac intensive care unit (CICU) and accounts for a substantial proportion of CICU patient deaths. Despite significant advances in revascularization techniques, pharmacologic therapeutics and mechanical support devices, CS remains associated with a high mortality rate. Indeed, the prevalence of CS within the CICU appears to be increasing. CS can be differentiated as phenotypes reflecting different metabolic, inflammatory, and hemodynamic profiles, depending also on anatomic substrate and congestion profile. Future prospective studies and clinical trials may further characterize these phenotypes and apply targeted intervention for each phenotype and SCAI SHOCK stage rather than a one-size-fits-all approach. Overall, there are 8 key concepts of CS; 1) the mortality associated with CS; 2) Shock attributed to AMI may be declining in both incidence and associated mortality; 3) providers should think about hemodynamic, metabolic, inflammation and cardiac function in totality to assess CS; 4) CS is a dynamic process; 5) no randomized trials evaluating use of the PAC in patients with CS; 6) most data supporting neosynephrine as first line agent in CS; 7) most registries suggest that almost half of CS patients do not have any mechanical support, and the vast majority of the remainder utilize the IABP; and 8) patients with AMI CS should receive emergent PCI of the culprit vessel.