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Review
. 2024 Dec 26;3(12):101402.
doi: 10.1016/j.jacadv.2024.101402. eCollection 2024 Dec.

Acute Decompensated Valvular Disease in the Intensive Care Unit

P Elliott Miller  1 , Balimkiz C Senman  2 , Ann Gage  3 , Anthony P Carnicelli  4 , Mark Jacobs  5 , Aniket S Rali  6   7 , Mourad H Senussi  8   9 , Ankeet S Bhatt  10   11 , Steven M Hollenberg  12 , Annapoorna Kini  13 , Venu Menon  14 , Kendra J Grubb  15 , David A Morrow  16 ; American College of Cardiology Critical Care Cardiology Section
Affiliations
Review

Acute Decompensated Valvular Disease in the Intensive Care Unit

P Elliott Miller et al. JACC Adv. .

Abstract

Acute decompensated valvular disease encompasses a group of complex and challenging conditions, which are often the primary reason for admission to the cardiac intensive care unit and can also complicate the management of other primary cardiac disorders. Critically ill patients with valvular disease also present unique diagnostic and management challenges. Historically, medical and percutaneous interventional therapies have been limited and surgery was the only definitive treatment; however, surgical risk can at times be prohibitive. High-quality evidence to direct management of acute valvular disorders in this population is lacking and societal guidelines largely do not address treatment options for critically ill patients with decompensated valvular disease. In this review, we discuss the clinical presentation and epidemiology of commonly encountered valvular diseases in the modern cardiac intensive care unit, highlight key pathophysiology, detail gaps in evidence, describe the pivotal role of multidisciplinary Heart Teams, and provide guidance for management.

Keywords: cardiac intensive care unit; cardiogenic shock; valvular disease.

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Conflict of interest statement

Dr Rali has received consulting/speaking honorarium from Analog Devices, Abiomed, Caretaker Medical, Vectorious, Volumetrix, and Zoll. Dr Bhatt has received consulting fees for programs sponsored by Sanofi. Dr Grubb is a speaker, proctor, and principal investigator for Edwards Lifesciences; is a speaker, proctor, and advisory board member for Boston Scientific; is a speaker, proctor, principal investigator, advisory board member, and national principal investigator for Medtronic; and her employer has research contracts for clinical investigation of transcatheter aortic, mitral, and tricuspid devices from Edwards Lifesciences, Abbott Vascular, Medtronic, and Boston Scientific. Dr Morrow has received research grant support to TIMI Study Group through Brigham and Women’s Hospital from Abbott Laboratories, Abiomed, Amgen, Anthos Therapeutics, Arca Biopharma, AstraZeneca, Daiichi-Sankyo, Intarcia, Janssen, Merck, Novartis, Pfizer, Poxel, Quark Pharmaceuticals, Regeneron, Roche, Siemens, and Zora Biosciences; and consulting fees from Abbott Laboratories, Arca Biopharma, InCarda, Inflammatix, Merck, Novartis, and Roche Diagnostics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Central Illustration
Central Illustration
Acute Decompensated Valvular Disease in the Intensive Care Unit Etiology, diagnostic, and management for right- and left-sided valvular disease. MS = mitral stenosis; PP = pulse pressure; TV = tricuspid valve; other abbreviations as in Figure 2, Figure 3, Figure 4 and 6.
Figure 1
Figure 1
Patient-Specific Factors Influencing Surgical Decisions Created in BioRender (2024). AV = aortic valve; BMI = body mass index; BP = blood pressure; CABG = coronary artery bypass grafting; LAP = left atrial pressure; LVEDV = left ventricular end-diastolic volume; NE = norepinephrine; SVR = systemic vascular resistance.
Figure 2
Figure 2
Key Points for Aortic Stenosis and Regurgitation Created in BioRender (2024). BAV = balloon aortic valvuloplasty; CO = cardiac output; ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump; LA-FA PVAD = left-atrial to femoral-artery percutaneous ventricular assist device; LAVA = left atrial-veno-arterial; LV = left ventricle; LVEDP = left ventricular end-diastolic pressure; MCS = mechanical circulatory support; MV = mitral valve; PAC = pulmonary artery catheter; SAVR = surgical aortic valve replacement; SBP = systolic blood pressure; SV = stroke volume; TAVR = transcatheter aortic valve replacement.
Figure 3
Figure 3
Temporary Mechanical Circulatory Support Treatment of Valvular Disease Created in BioRender (2024). AR = aortic regurgitation; AS = aortic stenosis; CI = cardiac index; LA = left atrium; other abbreviations as in Figure 2.
Figure 4
Figure 4
Key Points for Mitral Stenosis and Regurgitation Created in BioRender (2024). AMI = acute myocardial infarction; HR = heart rate; LAP = LA pressure; LVESV = LV end-systolic volume; MR = mitral regurgitation; NiPPV = noninvasive positive pressure ventilation; PBMV = percutaneous balloon mitral valvuloplasty; TEE = transesophageal echocardiogram; TEER = transcatheter edge-to-edge repair; TTE = transthoracic echocardiography; other abbreviations as in Figures 2 and 3.
Figure 5
Figure 5
Approach to Complicated Endocarditis in the CICU CAD = coronary artery disease; CICU = cardiac intensive care unit; CTICU = cardiothoracic intensive care unit; ICU = intensive care unit; SAR = subacute rehab.
Figure 6
Figure 6
Impact of Positive Pressure Ventilation on Valvular Heart Disease Created in BioRender (2024). PEEP = positive end-expiratory pressure; PVR = pulmonary vascular resistance; RV = right ventricle; other abbreviations as in Figures 2 and 4.
See this image and copyright information in PMC

References

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