Management of Critical Aortic Stenosis in Critically Ill Patients

Initial Assessment and Diagnosis

Echocardiography is the cornerstone for diagnosis and assessment of aortic stenosis severity, even in critically ill patients 3, 4
In low cardiac output states, diagnosis may be challenging but transthoracic echocardiography (TTE) findings are typically characteristic 1, 2

Balloon aortic valvuloplasty (BAV) is recommended as a bridge to definitive treatment in critically ill patients with cardiogenic shock 1, 2
The European Society of Cardiology recommends BAV as a bridge to definitive treatment with either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in hemodynamically unstable patients 1, 2
After stabilization with BAV, patients should be evaluated for definitive treatment with either TAVI or SAVR based on surgical risk assessment 5, 4

The decision between TAVI and SAVR should be made by a Heart Team based on surgical risk assessment 5, 4
The European Heart Society recommends TAVI over surgical AVR for high or extreme-risk patients due to porcelain aorta or hostile chest anatomy, multiple comorbidities, frailty or disability, or oxygen-dependent lung disease 5
SAVR remains appropriate for patients with low surgical risk, younger age, no contraindications to surgery, or long life expectancy 5

In patients with low-flow, low-gradient severe aortic stenosis with reduced ejection fraction, dobutamine stress echocardiography should be performed to confirm true stenosis severity 3, 4
Medical management alone is rarely appropriate for symptomatic patients with severe aortic stenosis, regardless of surgical risk 4
For patients with prohibitive surgical risk and life expectancy <1 year or moderate-to-severe dementia, palliative care with medical management may be considered 5, 4

After BAV as a bridge procedure, patients should be closely monitored for restenosis and prepared for definitive treatment 1, 2
Careful hemodynamic monitoring is essential during and after any intervention in critically ill patients with severe aortic stenosis 1, 4

Delaying intervention in symptomatic patients with severe aortic stenosis significantly increases mortality risk 6
Do not rely solely on transvalvular gradients for diagnosis in low-flow states; valve area calculation is essential 3, 4
Recognize that even modest regurgitation that develops acutely may cause severe pulmonary congestion and systemic hypotension in critically ill patients 1