Title: Saving the unsalvageable: Emergent transcatheter aortic valve-in-valve and transcatheter mitral valve-in-valve replacement for cardiogenic shock from dual bioprosthetic valve stenosis and insufficiency
Introduction
Cardiogenic shock (CS) is a life-threatening condition requiring prompt diagnosis and treatment. CS is a clinical diagnosis defined by low systolic blood pressure (<90 mm Hg for 30 minutes) or the need for vasopressors/inotropes to maintain blood pressure, along with signs of compromised organ perfusion. Severe valvulopathies are one of the causes of CS, but optimal management remains unclear. Urgent surgery is preferred; however, it might not be suitable for hemodynamically unstable, organ dysfunction patients. In situations where an individual is at high surgical risk, transcatheter valve replacement (TAVR) or valve-in-valve (VIV) implantation has emerged as a favored treatment option.
Clinical Case
A 72-year-old female with a history of aortic and mitral stenosis underwent bioprosthetic aortic and mitral valve replacement in 2016, Severe pulmonary hypertension and HFpEF presented with worsening sob and bilateral LE edema for two weeks. She was hypotensive (71/52 mm Hg), and hypoxic to 94% on 2L nc. Physical exam revealed JVD, rales, murmurs, cool extremities with pitting edema. Labs showed elevated BNP, creatinine, and liver enzymes. CXR showed pulmonary edema. TTE revealed severe aortic and mitral bioprosthetic valve stenosis, moderate to severe aortic insufficiency, and pulmonary hypertension. She was in CS, requiring vasopressors and inotropes. The cardiogenic shock team decided to proceed with emergent aortic VIV implantation followed by mitral VIV implantation. She underwent intubation, CRRT dialysis, transcatheter aortic VIV implantation, IABP placement, followed by mitral VIV implantation. Her hemodynamics improved post-valve-in-valve-implantation, but she required permanent dialysis.
Discussion
Bioprosthetic valves have a higher tendency of degeneration, especially in younger patients. MV bioprostheses degrade faster than AV bioprostheses with reoperation rates for bioprosthetic MV being 50% within 10 years, while for AV it's 10% within 10 years and 30% within 15 years. CS from AS has a significant short-term mortality rate of about 70%. In cases of acute HF or CS, TAVR procedures have shown promising results, reducing short-term mortality to around 35%., but data on degenerated prosthetic AV is limited. Similarly, for degenerated mitral valves, transcatheter-based treatments have been demonstrated through case reports. In cases of AI and CS, stabilization with intubation and hemodynamic support may be necessary prior to intervention. Surgical aortic valve replacement remains the primary choice, however, TAVR is an alternative for high-risk patients. CS management is challenging with high mortality risk. The approach to the management of CS is likely to be most effective when tailored to an individual’s case. In our patient’s case, the decision was made to prioritize urgent valve-in-valve implantation before considering mechanical support as her cardiogenic shock was secondary to valvular pathology and had concurrent moderate-severe aortic insufficiency.
Conclusion
This case underscores the complexity of managing CS from dual bioprosthetic valve stenosis and regurgitation. Percutaneous interventions offer a viable option for high-risk patients. Overall, in the management of intricate cases, a multidisciplinary cardiogenic shock team is crucial for effective management and improving patient survival.