LITERATURE
Outcomes best for all valvular disease in a Comprehensive Valve Center
VALVULAR EMERGENCIES
Thrombosed Left-Sided Mechanical Prosthetic Heart Valve
- Slow-infusion Low-Dose Firbrinolytic OR Emergency Surgery
Thrombosed Bioprosthetic Valve – symptomatic
- Surgical correction
- Transcatheter ViV (valve-in-valve) if surgery not feasible
- Reasonable to add VKA
Thrombosed Bioprosthetic Valve -stable
- VKA – oral
Hemolysis or HF from Prosthetic Transvalvular or Paravalvular Leak
- Surgical correction
- Percutaneous or Transcatheter ViV if surgery not feasible
Infective Endocarditis
- See ID Section
Acute Severe Regurgitant Valvular Heart Disease
- Target lowest BP for organ perfusion (pts are afterload sensitive)
- Volume overload and hypertension can worsen regurg
- Often need mechanical circulatory support with surgical correction ASAP for MR, Contraindicated in AR
- Medical therapies as Inotropes
- Epinephrine
- Can consider dobutamine or milrinone
- Avoid vasoconstrictors
- Medical therapies with Arterial Vasodilators (afterload reduction)
- Clevidipine (1-2mg/hr, max 21mg/hr)
- Nicardipine (5mg/hr, max 15mg/hr)
- Nitroprusside (5mcg/min, max 300mcg/min)
- Nitroglycerine (5mcg/min) – also preload reducer
Acute Mitral Regurgitation
- CFD: VC 0.7cm or greater (jet covering >40% LA area)
- Caused by
- Endocarditis; Papillary Muscle Rupture after MI; Chest Trauma; Chordal Rupture; Decompensation of PHTN; Prosthetic Valve Failure
Acute Aortic Regurgitation
- CFD: VC 0.6cm or greater (VC:LVOT ratio >0.65)
- CWD: PHT < 200ms
- Caused by
- Endocarditis; Type A Aortic Dissection; Chest Trauma; Iatrogenic; Prosthetic Valve Failure
Acute Severe Aortic Stenosis
- AV area <1 cm2
- Peak velocity >4 m/s
- Mean gradient >40mmHg
- Peak transvalvular pressure gradient > 40mmHg
- Caused by
- Degeneration, Rheumatic, Thrombosis
- Maintain diastolic BP
- Maintain adequate preload
- Avoid tachydardia
- Treat precipitating factors
- Often try to avoid intubation