Severe aortic stenosis and cardiogenic shock: A therapeutic challenge

Acute heart failure in patients with severe aortic stenosis and left ventricular systolic dysfunction is well known for its dire prognosis and limited therapeutic options.The authors describe the case of a man admitted for non-ST-elevation myocardial infarction. Diagnostic exams revealed severe aortic stenosis, with good left ventricular systolic function, and two-vessel coronary artery disease. The development of cardiogenic shock with left ventricular systolic dysfunction on day four led to changes in the therapeutic strategy. Percutaneous aortic balloon valvuloplasty coupled with complete myocardial revascularization was performed with a view to future surgical intervention. After discharge, the patient was readmitted with cardiogenic shock after acute pulmonary edema and cardiopulmonary arrest. Ventilator weaning was not possible due to acute heart failure and so it was decided to administer levosimendan, which resulted in substantial clinical and echocardiographic improvement. The patient subsequently underwent successful aortic valve replacement.This case highlights the challenge that characterizes the management of patients with concomitant coronary artery disease, left ventricular systolic dysfunction and severe aortic stenosis. Percutaneous aortic balloon valvuloplasty and levosimendan were safe and effective in the treatment of acute heart failure, acting as a bridge to surgery.

ResumoA insuficiência cardíaca aguda na estenose aórtica grave com compromisso da função sistólica global tem um prognóstico reservado, com opções terapêuticas limitadas.Os autores descrevem o caso clínico de um doente admitido por enfarte agudo do miocárdio sem supradesnivelamento de ST, no qual o estudo complementar revelou estenose aórtica grave, com boa função ventricular esquerda, e doença coronária de 2 vasos. O desenvolvimento de choque cardiogénico, com compromisso grave da função sistólica global, ao quarto dia de internamento, alterou a estratégia terapêutica, optando-se por realizar valvuloplastia aórtica com balão e revascularização miocárdica percutânea completa, com vista a posterior referenciação para cirurgia valvular. Após a alta, apresentou novo quadro de choque cardiogénico em contexto de insuficiência cardíaca aguda e paragem cardiorrespiratória. Por dificuldade na extubação, iniciou perfusão de levosimendan, com franca melhoria clínica e ecocardiográfica. Posteriormente, o doente foi submetido com sucesso a implantação de prótese valvular aórtica.Este caso demonstra o desafio que caracteriza a estabilização e o tratamento destes doentes. A valvuloplastia aórtica com balão e o levosimendan foram eficazes e seguros no tratamento da insuficiência cardíaca aguda e permitiram estabelecer a ponte para a cirurgia.