Assistant Professor of Medicine University of North Carolina The University of North Carolina at Chapel Hill Chapel Hill, North Carolina, United States
Disclosure(s):
William Mostertz, MD, MS, FACC, III: No financial relationships to disclose
Background: Valvular disease accounts for approximately 3-16% of cardiogenic shock. The management of this subset of cardiogenic shock patients is complex and must be tailored to each patient’s unique anatomy and hemodynamics. Here, we present a case of cardiogenic shock caused by critical stenosis of a bicuspid aortic valve.
Methods: A 59-year-old male former smoker with a history of hypertension, hyperlipidemia, type 2 diabetes, and bicuspid aortic valve presented to the emergency department with one day of chest pressure and dyspnea. He was previously known to have critical aortic valve stenosis, with peak transvalvular velocity 5.4 m/s and mean gradient 75 mmHg on recent echocardiogram. One week prior to presentation, he cancelled his scheduled surgical valve replacement due to financial concerns. In the emergency department, he was found to be hypotensive and hypoxemic. Blood gas was notable for pH 7.30, pCO2 41 mmHg, pO2 62 mmHg, and lactate 3.2 mmol/L. Noninvasive positive pressure ventilation was initiated, along with a norepinephrine infusion. He was transferred to our tertiary care center for consideration of expedited valve replacement. Upon arrival to our facility, the patient required immediate intubation for severe hypoxemia. He then developed severe hypotension, with mean arterial pressure < 50 mmHg despite three maximal-dose vasopressors. The patient was brought to the catheterization laboratory, where a multidisciplinary team including cardiac surgery, structural cardiology, cardiac anesthesia, and structural imaging prepared to initiate peripheral VA-ECMO. Before beginning, he suffered pulseless electrical activity requiring cardiopulmonary resuscitation. He was emergently cannulated bifemorally for VA-ECMO.
Outcome: Upon initiation of VA-ECMO, he also gained return of spontaneous circulation. Transesophageal echocardiogram revealed stasis of blood in the left atrium. Thus, the right atrial cannula was exchanged for a fenestrated cannula, which was placed across an atrial septostomy to establish a LAVA-ECMO circuit. The patient stabilized, and the decision was made to proceed with transcatheter aortic valve replacement. A 29 mm Edwards S3 valve was deployed. TEE showed no residual transvalvular gradient, however left ventricular ejection fraction was < 10%, with stasis of blood throughout the ventricle. Therefore, an Impella-CP (Abiomed, Danvers, MA) was placed for direct LV venting. With the Impella set to P2, the LV stasis resolved, but the left atrial free wall was inverting. Therefore, the fenestrated venous cannula was pulled back across the atrial septostomy into the right atrium, establishing a VA-ECMO with Impella-CP circuit, or ECPella. The patient was brought to the intensive care unit. His cardiac function improved steadily, enabling ECMO decannulation on day 5, and Impella removal the following day. His subsequent hospital course was complicated primarily by multifocal acute strokes with associated motor deficits. He was discharged to a rehabilitation facility and ultimately returned home with a full neurologic recovery.
Conclusion: Cardiogenic shock secondary to a valvular emergency requires prompt, multidisciplinary decision-making and action. This case illustrates a patient who made a full recovery after developing SCAI Stage E shock secondary to critical bicuspid aortic valve stenosis.
