Acute severe valvular emergencies: critical aortic stenosis, acute MR and AR

Also known as Critical aortic stenosis · Acute mitral regurgitation · Acute aortic regurgitation · Valvular emergency · Cardiogenic shock valvular · Balloon aortic valvuloplasty

Acute valvular emergencies present as cardiogenic shock, pulmonary oedema, or cardiac arrest. CRITICAL AORTIC STENOSIS (severe AS — area <1.0 cm², mean gradient 40): fixed outflow obstruction — preload-dependent, intolerance of AF/hypovolaemia, vasodilators dangerous. Definitive: aortic valve replacement (surgical or TAVI). Bridge: balloon aortic valvuloplasty (BAV) or VA-ECMO. ACUTE MITRAL REGURGITATION (papillary muscle rupture post-MI, endocarditis, chordal rupture): sudden volume overload on LA + pulmonary veins - flash pulmonary oedema + cardiogenic shock. Murmur may be SOFT (rapid equalisation of pressures). Echo diagnostic. Treatment: afterload reduction (nitroprusside, IABP), vasopressors/inotropes cautiously, definitive: urgent MV…

high21 referencesUpdated 26 July 202613 min readVerification in progress

Practise this topic

8 MCQs

The one-line answer

Acute valvular emergencies are three diseases that all present as unexplained shock or pulmonary oedema and all share one diagnostic key: the bedside echocardiogram, done early.^[1]

Critical aortic stenosis is a fixed outflow obstruction — preload- and contractility-dependent, so you maintain preload, maintain sinus rhythm (cardiovert unstable AF), and never vasodilate; definitive therapy is AVR (surgical or TAVI), bridged by balloon valvuloplasty or VA-ECMO. Acute mitral regurgitation (papillary muscle rupture, endocarditis) causes flash pulmonary oedema with a murmur that may be soft or absent — afterload reduction (nitroprusside, IABP) is the bridge to urgent surgery. Acute aortic regurgitation (dissection, endocarditis) causes diastolic run-off with a murmur that may be short and a pulse pressure that may be normal in the acute setting — the IABP is absolutely contraindicated, and the definitive therapy is urgent AVR.^[1]^[2]

Meet the patient

GTN in critical AS. A 78-year-old man with known aortic stenosis presents with syncope and breathlessness — BP 84 over 50, fast atrial fibrillation at 130, cold peripheries, pulmonary oedema on chest X-ray. A GTN infusion to drop the afterload collapses systolic BP to 60 within minutes. Bedside echo shows a critically calcified aortic valve with a mean gradient of 48 mmHg and a severely hypertrophied, underfilled LV.^[1]

Valve, then rule. The two questions that decide his next hour decide every valvular emergency: which valve, and what is its haemodynamic rule. Critical AS needs preload and afterload maintained; acute MR needs afterload reduced; acute AR needs the diastolic pressure defended and the IABP avoided. Get the echo early — before reaching for any vasoactive drug — because the wrong drug in the wrong valve kills.^[1]

References21Show

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