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Aortic Stenosis in the Emergency Department

Many people with severe AS will know they have a history of aortic valve disease. If they’re not aware or able to give you the history, they may have previous echocardiogram reports on record demonstrating AS. Without these history features being gifted to you in one of the previous ways, people with severe AS may present with typical history of angina, decreased exercise tolerance or exertional dyspnea, and presyncope/syncope. Syncope is a particularly important history feature as patient with severe aortic stenosis and a history of syncope have a poorer prognosis.

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 Decoding Critical Aortic Stenosis: A Guide to Spotting the Heart's Sneaky Traffic Jam with Ultrasound

Aortic stenosis (AS) is the most common valvular disease in the developed world and carries a high mortality rate in symptomatic patients. Etiologies of AS can be congenital (think bicuspid aortic valve), calcific, and rheumatic. Clinical deterioration occurs rapidly within two to three years of symptoms if left untreated. The most common symptoms of AS include angina, syncope, and heart failure which are all common presentations in the emergency department (ED).

 The Crashing Patient with Critical Aortic Stenosis

Critical aortic stenosis (AS) is the single most problematic valvular disease we encounter in the emergency department. Patients with critical AS have a fixed cardiac output and cannot meaningfully increase cardiac output to meet the physiologic demands of critical illness. Avoiding systemic hypotension, maintaining sinus rhythm, and avoiding excessive tachycardia are therefore the cornerstones of resuscitation.

Articles of Interest

Aortic Stenosis with A Fib and CHF

The management of patients with aortic stenosis can be tenuous at the best of times. When these patients present with CHF or dysrhythmias, their management is much more nuanced than the typical patient presenting with the same complaints. This case nicely highlights the following management differences...

Acute Valve Disasters Part 2 – Management of Critical Aortic Stenosis

AS without intervention can deteriorate to acute decompensated heart failure and cardiogenic shock due to either progressive valve and myocardial dysfunction or perhaps even more frequently, a superimposed disease process. Life expectancy is only 1-2 years after the development of symptoms of LV failure with only an 18% survival to 5 years.

Crashing Aortic Stenosis

75 yr Fijian old male presenting to hospital following syncopal episode while walking upstairs in his home. Initial ED arrival with GCS 15 but appears tachypneic and dyspneic. Initial VS are normotensive but tachycardic and tachypnic. Patient will eventually progress to hypotension and likely arrest regardless of learner actions but will arrest more promptly if aggressive diuresis or aggressive preload reduction. If patient arrests he will develop V.Fib arrest due to coronary hypoperfusion with progression from V.Fib to PEA to ROSC. Following ROSC learner will need to consult Cardiology and/or Cardiovascular/Thoracic Surgery and request CCU admission and consideration for balloon valvulotomy vs LVAD bridge to therapy to definitive surgical valvular management.

EM@3AM: Aortic Stenosis

Aortic stenosis causing acute decompensated systolic and diastolic heart failure, and cardiogenic shock.

Emergency Treatment of Acute Decompensated Critical Aortic Stenosis With Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is relatively contraindicated in the bicuspid aortic valve, and to our knowledge has not been tried where the true native annulus is of a size far in excess of current device capabilities. We present here a case of a successful emergency TAVI of a 73-year-old previously healthy man, who presented with cardiogenic shock, ventricular tachycardia storm and severe left ventricular dysfunction because of the underlying critical bicuspid aortic stenosis with aortic annulus area of 991.9 mm2 and associated moderate aortic incompetence

Emergency treatment of decompensated aortic stenosis

The optimal treatment of patients with acute and severe decompensation of aortic stenosis is unclear due to recent advances in transcatheter interventions and supportive therapies. Our aim was to assess the early outcome of emergency transcatheter aortic valve implantation (eTAVI) versus emergency balloon aortic valvuloplasty (eBAV) followed by TAVI under elective circumstances.

Hocus Pocus for Aortic Stenosis in the ED

AS is classically seen in an older patient presenting with syncope, angina, and/or dyspnea. On physical exam, they are found to have a harsh, late-peaking systolic murmur at the right upper sternal boarder that radiates to the carotids. Unfortunately, this classic symptom triad isn’t usually present until late in the disease process meaning if we wait for those symptoms, there may already be irreversible damage to the heart. Symptomatic AS patients have a mortality rate of about 25% per year. Given the effectiveness and availability of transcatheter aortic valve replacement (TAVR), early identification of AS is crucial to prevent progression to severe disease and is something that we can do, even in the middle of the busy ED, to decrease morbidity and mortality for these patients.

Management of the Crashing Aortic Stenosis Patient

Diagnosis of new onset aortic stenosis in the Emergency Department can be difficult. Patients may present with syncope, angina, and/or dyspnea, but this depends on the severity of disease. On exam, a murmur may be auscultated that is classically a crescendo-decrescendo systolic ejection murmur that radiates to the carotids. ECG commonly shows signs of left-ventricular hypertrophy and nonspecific ST-wave and T-wave abnormalities. Chest radiography may depict a boot shaped heart. Echocardiogram is the diagnostic test of choice.

The Critically Ill Patient with Aortic Stenosis

Patients with severe aortic stenosis who present with acute decompensated heart failure are among the most challenging patients to resuscitate. In this podcast, we discuss the pearls and pitfalls in managing both the hypertensive and hypotensive patient with severe AS and acute heart failure.

The Way is Shut: Aortic Stenosis

Unfortunately, no medical therapies influence the natural history of aortic stenosis. Aortic valve replacement (AVR), remains, to date, the only therapeutic option to improve the survival of patients with symptomatic severe AS. Luckily, we have made incredible advances in this area in the last 2 decades, with the first TAVI (transcatheter aortic valve implantation) performed in 2002, revolutionizing the treatment of AS and providing a minimally invasive option for patients who may not have otherwise been candidates for traditional surgery.

Treatment of Cardiogenic Shock in Severe Aortic Stenosis With the Edwards INTUITY Valve

Acute cardiogenic shock (CS) in patients with severe aortic stenosis and left ventricular (LV) systolic dysfunction is associated with a poor prognosis. Recent guidelines suggest that percutaneous aortic balloon valvuloplasty can provide a temporary “bridge” to aortic valve replacement or transcatheter aortic valve implantation (TAVI) or be used as palliative treatment (level of evidence IIb C). However, aortic balloon valvuloplasty is associated with a high rate of procedural complications

Resources

Edwards Intuity Elite valve system

We have combined our proven pericardial valve technology with our innovations in transcatheter heart valves to create a surgical valve designed to streamline procedures and facilitate smaller incision surgery. We believe more efficient, less invasive procedures can provide significant benefits, both during the procedure and after.