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32. Cardiovascular Nursing
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The hole of hope: aortic stenosis complicated by cardiogenic shock
Session:
Casos Clinicos
Speaker:
Sofia Alegria
Congress:
CPC 2020
Topic:
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Theme:
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Subtheme:
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Session Type:
Comunicações Orais
FP Number:
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Authors:
Sofia Alegria; Laura Martinez; Maria Dolores Cosio; Javier De Juan Baguda; Pedro Caravaca; Zorba Blázquez; Fernando Sarnago; M. Velázquez; Enrique Perez de la Sota; Andrea Eixéres; J. Pérez-Vela; Juan Delgado
Abstract
<p>We report the case of a 48 year-old patient who presented with fatigue and dyspnea to minimal efforts. On admission he was hypotensive (mean blood pressure of 60 mmHg) and tachycardic (heart rate of 170 /minute), with signs of poor perfusion and respiratory distress; oxygen saturation was 96% on 100% oxygen from a non-rebreathing reservoir mask; pulmonary auscultation revealed disperse rales. The electrocardiogram showed supraventricular tachycardia. Fast-track transthoracic echocardiogram (TTE) documented left ventricle (LV) dilatation, with diffuse hypokinesia and estimated ejection fraction (EF) of 5%.</p> <p>He was intubated, admitted in the intensive care unit, and started on inotropic and vasopressor support, but remained in refractory cardiogenic shock (CS), so an intra-aortic balloon pump was implanted. Due to lack of significant improvement, peripheral femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support was initiated. In the first days, the patient presented with multiorgan failure requiring transient renal replacement therapy.</p> <p>Transesophageal echocardiogram showed LV dilatation with EF below 10%; bicuspid aortic valve, with significant calcification and restriction of opening, associated with low-flow low-gradient aortic stenosis (AS) (mean gradient 19 mmHg, aortic valve area 0.65 cm<sup>2</sup>), and moderate regurgitation. Coronary angiography excluded significant lesions.</p> <p>Eleven days after admission he was extubated, but two days later presented with refractory pulmonary edema, leading to reintubation, despite medical optimization and hemofiltration. This was attributed to increased LV afterload associated with ECMO support, so it was decided to perform percutaneous balloon atrioseptostomy (BAS), with progressive dilatation (maximum balloon diameter of 14 mm). This lead to resolution of pulmonary edema, recovery of diuresis (Table 1) and extubation after 48 hours.</p> <p>Computed tomography angiography documented a large aortic annulus that was unfavorable to transcatheter AVR, so, after heart team discussion, he was submitted to surgical AVR (Sorin Bicarbon 25 mechanical prosthesis).</p> <p>The postoperative course was favorable, and TTE at discharge documented an EF of 40% and mechanical prosthesis with normal function.</p> <p>After 17 months of follow-up, the patient is in NYHA functional class I, with an EF of 50%.</p> <p>This case provides new insights in the management of AS complicated by CS, highlighting the role of BAS, which is a simple and inexpensive technique to unload the LV, allowing the hemodynamic stabilization of the patient as a bridge to definitive therapy.</p> <p> </p>
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