Internal Medicine Resident University of Texas Southwestern Medical Center Dallas, Texas, United States
Disclosure(s):
Frans Serpa, MD: No financial relationships to disclose
Background: Acute heart failure (HF) in the presence of severe multi-valvular pathology presents complex hemodynamic and management challenges that require timely diagnosis and treatment. Our objective is to present a multidisciplinary approach to the management of severe acute HF in the background of severe mitral, aortic, and tricuspid valve regurgitation.
Methods: Hospital records were reviewed to describe this clinical case.
Outcome: An 81-year-old man with tobacco use and chronic anemia from small bowel AVMs presented to an outside hospital with sudden-onset dyspnea and hemoptysis. Echocardiogram revealed severe MR, AS, and TR. He was transferred to our institution for further care. On arrival, he was hypoxemic, requiring HFNC (8 L/min). Imaging demonstrated diffuse GGO (Figure A). Echocardiogram showed hyperdynamic LVEF (70%), confirmed severe AS, severe eccentric anteriorly directed MR due to flail posterior leaflet (Figure B), a mean trans-mitral gradient of 10 mmHg (Figure C), and moderate to severe TR.
Based on the normal LA size and acute symptom onset, we deduced that MR was the primary valvular culprit. Sodium nitroprusside was added to diuretic therapy. Structural interventional cardiology and cardiothoracic surgery teams were consulted. M-TEER was prohibitive due to anatomy and trans-mitral valve gradient, thus valve surgery was offered. RHC (87/40 mmHg) revealed low CI (2.0 L/min/m²), elevated biventricular filling pressures, and a large PCWP V-wave (Figure D). LHC showed severe mid-RCA disease at 90%. An IABP was placed with low-dose heparin goal, and a PA catheter was used for hemodynamic optimization. The patient subsequently underwent successful chordal sparing MVR (27 mm Mitris), AVR (21 mm Inspiris), and CABGx1 (SVG-RPL).
Conclusion: Acute HF and cardiogenic shock in the setting of severe multi-valvular disease requires rapid stabilization and identification of the hemodynamically dominant valve lesion to guide optimal therapy. A Heart Team capable of both surgical and transcatheter techniques is key in the care of these critically ill patients
