Transcatheter Aortic Valve Implantation in Cardiogenic Shock: Current Evidence, Clinical Challenges, and Future Directions

Abstract

Cardiogenic shock (CS) in the setting of severe aortic stenosis (AS) presents a critical and high-risk scenario with limited therapeutic options and poor prognosis. Transcatheter aortic valve implantation (TAVI), initially reserved for inoperable or high-risk surgical candidates, is increasingly being considered in patients with CS due to improvements in device technology, operator experience, and supportive care. This review synthesizes current evidence from large registries, observational studies, and meta-analyses that support the feasibility, safety, and potential survival benefit of urgent or emergent TAVI in selected CS patients. Procedural success is high, and early intervention appears to confer improved short-term and mid-term outcomes compared to balloon aortic valvuloplasty or medical therapy alone. Critical factors influencing prognosis include lactate levels, left ventricular ejection fraction, renal function, and timing of intervention. The absence of formal guidelines, logistical constraints, and ethical concerns complicate decision-making in this unstable population. A multidisciplinary Heart Team/Shock Team approach is essential to identify appropriate candidates, manage procedural risk, and guide post-intervention care. Further studies and the development of TAVI-specific risk models in CS are anticipated to refine patient selection and therapeutic strategies. TAVI may represent a transformative option for stabilizing hemodynamics and improving outcomes in this otherwise high-mortality group.

Keywords: aortic stenosis; cardiogenic shock; heart failure; transcatheter aortic valve implantation (TAVI).

Figure 1

A schematic representation of the pathophysiological progression from severe aortic stenosis to cardiogenic shock. LV, left ventricular; ↓, decrease; ↑, increase.

Figure 2

A conceptual diagram illustrating the therapeutic role of transcatheter aortic valve implantation in restoring hemodynamic stability in cardiogenic shock. TAVI, transcatheter aortic valve implantation.

Figure 3

Practical considerations in transcatheter aortic valve implantation procedure during cardiogenic shock. TAVI, transcatheter aortic valve implantation; BAV, balloon aortic valvuloplasty; MCS, mechanical circulatory support; IABP, intra-aortic balloon pump; LV, left ventricle; ECMO, extracorporeal membrane oxygenation; CTCA, computed tomography coronary angiography; TOE, transoesophageal echocardiography; CAD, coronary artery disease; ACS, acute coronary syndrome.