Valvular diseases

Valvular lesion	Common ECG findings	Common CXR findings
Aortic stenosis	Left ventricular hypertrophy (LVH)	Enlarged cardiac silhouette, aortic calcifications, potential pulmonary edema
Aortic regurgitation (chronic)	LVH, left heart strain	May have no acute findings
Aortic regurgitation (acute)	May have no acute findings	Widened mediastinum, enlarged cardiac silhouette
Mitral stenosis	P mitrale due to LA enlargement, potential AF	May have no acute findings
Mitral regurgitation (chronic)	P mitrale due to LA enlargement, potential AF	Enlarged LA and LV
Mitral regurgitation (acute)	No specific changes related to valvular disease, though may indicate underlying etiology (e.g., STEMI)	Severe pulmonary edema

Sudden deterioration and critical management

General principles
- Initial management should focus on acute stabilization:
  - Expectant airway management
  - Supplemental oxygen
  - Cardiac monitoring.
- Following stabilization, treatment should be symptom-focused.
- Acute valvular dysfunction is usually secondary to a precipitating critical problem. The latter will have to be addressed as well.
Lesion-specific issues
- Aortic stenosis:
  - Patients with AS are exquisitely sensitive to preload.
  - Exaggerated hypotension after intubation should be anticipated.
  - Depending on the underlying pathology, hemodynamics may be optimized by controlling the heart rate and increasing stroke volume.
  - In patients with acute CHF, afterload reduction will decrease the pressure gradient across the valve.
  - Loop diuretics should be used judiciously.
- Acute aortic regurgitation:
  - Like acute MR, this is a true medical emergency and often presents with acute onset dyspnea from CHF.
  - Early medical management focuses on lowering LV end-diastolic pressure and increasing forward flow by reducing afterload.
  - IV nitroprusside or other vasodilators can be used for afterload reduction.
  - Cardiac inotropes such as dobutamine or dopamine can help increase contractility.
  - Avoid beta-blockers in the acute setting.
  - Unlike in MR, the use of intra-aortic balloon pumps is contraindicated since inflation of the balloon during diastole will worsen the severity of AR.
  - Treat other causes of acute AR such as infective endocarditis or aortic dissection.
  - The mainstay of treatment is early surgery to replace or repair the incompetent valve.
- Mitral stenosis:
  - Like AS, it may impact hemodynamics but does not often present critically.
  - Heart rate control may improve hemodynamics.
- Acute mitral regurgitation:
  - This is a medical emergency, as patients typically present in acute pulmonary edema and cardiogenic shock.
  - Early medical management focuses on the reduction of afterload to increase ventricular ejection fraction, and therefore reduce regurgitant volume.
  - If the patient is hypotensive, nitroprusside should be administered along with dobutamine.
  - Intra-aortic balloon pumps are often used to increase cardiac output.
  - Mild to moderate tachycardia may be beneficial as it limits the amount of regurgitation. Beta-blockers should therefore be avoided.
  - Surgical management is the mainstay of treatment in most cases of acute MR.
  - MR secondary to myocardial ischemia may be managed with early revascularization to restore blood flow to the papillary muscles.

Critical care considerations

Vasopressor of choice: while there is no good evidence on the use of pressors in patients presenting with hypotension and shock related to acute valvular emergency, vasopressors with primarily vasoconstrictive effects such as phenylephrine should be avoided as they increase afterload and decrease cardiac output. The following pressors and/or inotropes can be considered:

SBP 80 mmHg: dobutamine
SBP <80 mmHg: dopamine
SBP <70 mmHg: norepinephrine.