Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery

Abstract

Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.

Central illustration. Diagnostic and therapeutic algorithm in cardiogenic shock and valvular heart disease.

Diagnostic and therapeutic algorithm leading to valve intervention when valvular heart disease is either the primary cause or an aggravating factor in cardiogenic shock. *The mentioned valve disorders are the most common examples. PCI: percutaneous coronary intervention; PVL: paravalvular leak; TAVI: transcatheter aortic valve implantation; TEER: transcatheter edge-to-edge repair; VHD: valvular heart disease

Figure 1. Identification of BVF mechanisms associated with cardiogenic shock.

*for HVD severity definition. *Stage 1 HVD definition: evidence of SVD, non-structural valve dysfunction (other than paravalvular regurgitation or prosthesis-patient mismatch), thrombosis, or endocarditis without significant haemodynamic changes. *Stage 2 HVD definition: increase in mean transvalvular gradient ≥10 mmHg resulting in a mean gradient ≥20 mmHg with a concomitant decrease in EOA ≥0.3 cm² or ≥25% and/or decrease in Doppler velocity index ≥0.1 or ≥20% compared with echocardiographic assessment performed 1-3 months post-procedure, OR new occurrence or increase of ≥1 grade of intraprosthetic AR resulting in ≥moderate AR. *Stage 3 HVD definition: increase in mean transvalvular gradient ≥20 mmHg resulting in a mean gradient ≥30 mmHg with a concomitant decrease in EOA ≥0.6 cm² or ≥50% and/or decrease in Doppler velocity index ≥0.2 or ≥40% compared with echocardiographic assessment performed 1-3 months post-procedure, OR new occurrence or increase of ≥2 grades of intraprosthetic AR resulting in severe AR. AR: aortic regurgitation; BV: bioprosthetic valve; BVF: bioprosthetic valve failure; EOA: effective orifice area; HALT: hypoattenuated leaflet thickening; HVD: haemodynamic valve deterioration; MSCT: multislice computed tomography; PVL: paravalvular leak; RLM: reduced leaflet motion; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography

Figure 2. Proposed diagnostic workflow for the assessment of patients presenting with CS.

Step 1. Point-of-care cardiac ultrasound. A point-of-care cardiac ultrasound is generally useful as it provides the first clues of severe VHD. However, it is rarely sufficient. In this phase, ruling out acute myocardial ischaemia, advanced cardiomyopathies, untolerated arrhythmias, acute pulmonary embolism, tamponade or type A acute aortic dissection potentially responsible for the CS, is crucial. When a point-of-care cardiac ultrasound reveals hyperdynamic LV function in a patient with severe acute decompensated heart failure or CS, urgent assessment with comprehensive transthoracic echocardiography (TTE) is warranted to exclude VHD emergencies. Step 2. Comprehensive TTE. Comprehensive TTE is generally adequate to accurately investigate valve structure and function. Importantly, increased flow due to sepsis or anaemia can elevate Doppler gradients, potentially leading to overestimation of the severity of stenotic valve lesions. Likewise, volume overload and systemic hypertension often lead to reversible worsening of regurgitant lesion severity. Conversely, low-flow status might underestimate the severity of valvular diseases. Invasive coronary angiography±invasive haemodynamic assessment can give additional information in this step. At this step, an invasive coronary angiography is indicated to rule out concomitant CAD according to guideline criteria. Alternatively, owing to its high negative predictive value, MSCT may be used in patients who are at low risk of atherosclerosis. Step 3. Complementary valve-specific diagnostic tools include TOE and/or multislice computed tomography. Accurate quantification of VHD severity is essential, as only severe valvular dysfunction can cause CS. Hence, TOE, including three-dimensional modalities, is useful in the detailed assessment of valve anatomy and function (native or prosthetic) and should be systematically performed when TTE is inconclusive. In stabilised patients, MSCT should be performed if required for the planification of the transcatheter heart valve intervention. AMI: acute myocardial infarction; CAD: coronary artery disease; CS: cardiogenic shock; ECG: electrocardiogram; LV: left ventricular; MSCT: multislice computed tomography; PMBV: percutaneous mitral balloon valvuloplasty; TAVI: transcatheter aortic valve implantation; TEER: transcatheter edge-to-edge repair; TMVI: transcatheter mitral valve implantation; TOE: transoesophageal echocardiography; VHD: valvular heart disease; ViV: valve-in-valve

Figure 3. Factors influencing utility versus futility of emergent TAVI in case of patients with AS and CS.

AS: aortic stenosis; BAV: balloon aortic valvuloplasty; CS: cardiogenic shock; CT: computed tomography; TAVI: transcatheter aortic valve implantation