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cardio.cardiogenic-shock.acute-aortic-regurgitation.v1

Cardiogenic shock — acute severe aortic regurgitation

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to acute severe aortic regurgitation with cardiogenic shock per Otto ACC/AHA 2020 valvular heart disease guideline (PMID 33342587) + Vahanian ESC 2021 valvular (PMID 34453165). Etiology spectrum: Stanford Type A aortic dissection extending into root with cusp prolapse (commonest life-threatening etiology); infective endocarditis (S. aureus, Strep viridans) with leaflet perforation / paravalvular abscess; blunt chest trauma (steering wheel, fall); iatrogenic (TAVR malposition / paravalvular leak / valvuloplasty leaflet tear); spontaneous cusp rupture (bicuspid valve, Marfan, Ehlers-Danlos). Hemodynamics CRITICAL — OPPOSITE TO CHRONIC AR: rapid LV volume overload into normal-sized non-compliant LV (no chronic eccentric hypertrophy) → very high LVEDP → flash pulmonary edema + low forward CO → cardiogenic shock; LVEDP rise can EXCEED LA pressure causing premature mitral valve closure (M-mode echo finding); NARROW pulse pressure + tachycardia (compensatory) — NO classic chronic AR signs (Corrigan, de Musset, Quincke, etc. NOT present). Diagnosis: STAT TEE is the diagnostic anchor — vena contracta ≥0.6 cm, holodiastolic flow reversal in descending aorta, PHT <250 ms (severe), cusp tear / perforation / dissection flap visualization, paravalvular abscess if endocarditis; CTA chest MANDATORY for Type A dissection rule-out; ECG (sinus tachy + LV strain; STEMI pattern if dissection extending to coronary ostium); CXR (flash edema + normal/mildly dilated cardiac silhouette + widened mediastinum if dissection); bedside echo (premature mitral valve closure on M-mode is diagnostic). Treatment ACUTE: EMERGENT SURGICAL AV repair / replacement is definitive (Class I per ACC/AHA 2020); concurrent aortic repair if Type A dissection; AVOID IABP — diastolic augmentation INCREASES regurgitant volume (CONTRAINDICATED); AVOID β-blocker pre-surgery — loss of compensatory tachycardia worsens forward flow (different from dissection-only HR-control management); sodium NITROPRUSSIDE afterload reduction is cornerstone pharmacologic bridge (reduces SVR → reduces regurgitant fraction); DOBUTAMINE inotrope preferred (supports forward flow without major SVR rise); NE only when needed for MAP ≥65 in minimum dose (SVR rise worsens AR); intubation often needed for refractory pulm edema; empiric vancomycin + ceftriaxone if endocarditis suspected per AHA 2015 (Baddour PMID 26373316). Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for acute AR — IABP CONTRAINDICATED, β-blocker AVOIDED pre-surgery (resolved post-op), nitroprusside cornerstone, mandatory CTA for dissection rule-out, concurrent aortic + valve surgery if Type A, lifelong aortic surveillance if dissection / connective tissue disease, genetic testing for Marfan / EDS. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 17 acute valvular variant.

Entry points (5)

  • symptom
    Sudden chest / back pain + new diastolic murmur + flash pulmonary edema + cardiogenic shock → acute severe AR with concurrent dissection until proven otherwise
    sudden_chest_pain_with_flash_pulm_edema
  • imaging
    STAT TEE: vena contracta ≥0.6 cm, holodiastolic flow reversal in descending aorta, premature mitral valve closure on M-mode, PHT <250 ms + biventricular dysfunction + shock physiology
    tee_acute_severe_ar_premature_mitral_closure
  • imaging
    CTA chest: Stanford Type A aortic dissection extending into root with cusp prolapse + acute severe AR + cardiogenic shock — concurrent surgical emergency
    cta_chest_type_a_dissection_with_ar
  • symptom
    Active infective endocarditis (S. aureus, Streptococcus) + acute hemodynamic deterioration + new diastolic murmur → aortic leaflet perforation / paravalvular abscess
    acute_endocarditis_with_aortic_decompensation
  • history
    Recent blunt chest trauma + new diastolic murmur + hemodynamic compromise → traumatic aortic leaflet tear / commissural disruption
    recent_chest_trauma_with_diastolic_murmur

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Younger patients (Marfan, Ehlers-Danlos, bicuspid valve) over-represented in spontaneous cusp rupture; older patients in dissection / endocarditis; informs surgical-risk + connective tissue evaluation
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; gates vasopressor escalation; SBP <90 with flash pulm edema is the cardinal acute AR + CS presentation
  • hrrequired
    vital • used at CONTEXT
    COMPENSATORY TACHYCARDIA maintains forward flow in acute AR — DO NOT suppress with β-blocker pre-surgery (diastolic prolongation worsens regurgitation)
  • spo2required
    vital • used at INITIAL_WORKUP
    Flash pulmonary edema severity tracker; intubation often needed
  • pulse_pressurerequired
    vital • used at CONTEXT
    NARROW pulse pressure in acute AR (opposite to chronic AR wide pulse pressure) — cardinal hemodynamic finding
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Elevated if etiology is dissection extending to coronary ostium or concurrent ischemia
  • d_dimerrequired
    lab • used at INITIAL_WORKUP
    Aortic dissection screen — markedly elevated D-dimer raises pretest probability for dissection
  • bnp_ntprobnprequired
    lab • used at INITIAL_WORKUP
    Acute volume overload marker; trend tracks decongestion + recovery
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2022 staging + response to therapy; CardShock prognostication (Harjola EHJ 2015 PMID 26333869)
  • creatininerequired
    lab • used at CONTEXT
    End-organ damage marker + dose adjustment for nitroprusside (cyanide accumulation); contrast nephropathy risk for CTA
  • blood_culturesrequired
    lab • used at INITIAL_WORKUP
    Active endocarditis is a major etiology of acute AR; obtain × 3 sets before any antibiotics
  • echorequired
    imaging • used at INITIAL_WORKUP
    Bedside TTE for initial screen — diastolic mitral valve closure (M-mode), AR jet, biventricular function; PRELIMINARY only — TEE is gold standard
  • teerequired
    imaging • used at BRANCHING_WORKUP
    GOLD STANDARD — vena contracta ≥0.6 cm, holodiastolic flow reversal in descending aorta, PHT <250 ms (severe), cusp tear / perforation / dissection flap visualization, paravalvular abscess if endocarditis
  • cta_chestrequired
    imaging • used at BRANCHING_WORKUP
    MANDATORY rule-out of Stanford Type A aortic dissection (most common life-threatening etiology); identifies extension to root + branch involvement
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Sinus tachycardia (compensatory) + LV strain; STEMI pattern if dissection extending to coronary ostium
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Flash pulmonary edema + normal or mildly dilated cardiac silhouette + widened mediastinum if dissection
  • aortic_disease_history
    history • used at CONTEXT
    Pre-existing bicuspid aortic valve, prior aneurysm, connective tissue disease (Marfan, Ehlers-Danlos), prior aortic surgery
  • recent_chest_trauma
    history • used at CONTEXT
    Blunt chest trauma → leaflet tear / commissural disruption
  • recent_valve_intervention
    history • used at CONTEXT
    Recent TAVR (paravalvular leak) / balloon valvuloplasty / surgical valve manipulation

12-phase flow (11)

  1. 1FRAME
    Confirm acute severe AR as the cardiogenic shock etiology — sudden flash pulm edema + new diastolic murmur + biventricular dysfunction + NARROW pulse pressure (opposite to chronic AR); identify suspected sub-etiology (Type A dissection vs endocarditis vs trauma vs iatrogenic) which drives surgical urgency; CTA chest is mandatory rule-out for dissection
    inputs: echo, cxr
    advance: Acute severe AR confirmed and dissection screened
  2. 2ENTRY
    CS team activation INCLUDING cardiothoracic surgery from minute 0 — emergent surgery is the only definitive treatment; mobilize STAT TEE + CTA chest; AVOID IABP (worsens AR); AVOID β-blocker pre-surgery (suppresses compensatory tachycardia)
    inputs: sbp, lactate
    advance: CS team + cardiothoracic surgery + STAT TEE + CTA activated; IABP and β-blocker contraindications flagged
  3. 3CONTEXT
    Aortic disease history (bicuspid valve, prior aneurysm, connective tissue disease), endocarditis exposure, recent trauma, recent valve intervention, allergies, code status; PULSE PRESSURE is narrow (opposite to chronic AR)
    inputs: hr, creatinine, pulse_pressure, aortic_disease_history
    advance: Context complete and sub-etiology working hypothesis stated
  4. 4RED_FLAGS
    Pre-arrest physiology, refractory pulmonary edema requiring intubation (very common), Type A dissection confirmed → emergent concurrent aortic + valve surgery, refractory shock despite afterload reduction → expedite surgery; IABP-error (placed before TEE diagnosis) → remove immediately; β-blocker exposure error pre-surgery → stop and resuscitate
    inputs: sbp, spo2
    actions: acute_valvular_emergency, cardiogenic_shock
    advance: Mechanical emergency screened, surgery activated, contraindicated interventions identified and reversed
  5. 5INITIAL_WORKUP
    ECG (sinus tachy + LV strain), bedside echo (premature mitral valve closure on M-mode is diagnostic), troponin, D-dimer, BNP, BMP, lactate, blood cultures × 3, CXR (flash edema + widened mediastinum if dissection), CBC, coags
    inputs: ecg, echo, troponin, d_dimer, bnp_ntprobnp, lactate, blood_cultures, cxr
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg, panel.coag
    advance: Workup complete and SCAI stage assigned
  6. 6BRANCHING_WORKUP
    STAT TEE — gold standard mechanism + severity (vena contracta ≥0.6 cm, PHT <250 ms, holodiastolic flow reversal, premature mitral closure); CTA chest MANDATORY for dissection rule-out; coronary angiography if STEMI pattern (dissection extending to coronary ostium); blood cultures pending if endocarditis
    inputs: tee, cta_chest
    advance: Mechanism confirmed by TEE + dissection ruled out / confirmed by CTA + surgical plan documented
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication; surgical-risk stratification (STS / EuroSCORE) for surgical decision; concurrent dissection markedly increases operative complexity and mortality (Type A dissection mortality without surgery ≈1-2% per hour from onset per IRAD)
    inputs: sbp, lactate, troponin
    advance: Risk stratified, surgical candidacy assessed
  8. 8TREATMENT
    EMERGENT SURGICAL AV repair / replacement (Class I per ACC/AHA 2020); concurrent aortic repair if Type A dissection; AVOID IABP (worsens AR — diastolic augmentation increases regurgitant volume); AVOID β-blocker pre-surgery (loss of compensatory tachycardia worsens forward flow); sodium nitroprusside afterload reduction (cornerstone bridge); dobutamine inotrope; NE only when needed for MAP ≥65 (minimize — increases SVR worsens AR); intubation often needed; empiric vancomycin + ceftriaxone if endocarditis suspected
    inputs: sbp, lactate
    actions: acute_valvular_emergency
    advance: Surgical plan active + nitroprusside running + IABP and β-blocker AVOIDED + appropriate pharmacologic support running
  9. 9DISPOSITION
    Direct OR transfer for emergent valve / aortic surgery (Class I); if unstable, ICU bridge then OR; advanced HF / transplant capable center if not local; CICU at MCS-capable center if non-operative bridge
    advance: Disposition assigned with MDT mobilised (cards, CT surgery, vascular surgery, IC, advanced HF, ID if endocarditis)
  10. 10MONITORING
    A-line, central line, lactate clearance, urine output; continuous telemetry; serial echo q12-24h post-surgery for valve function + LV recovery; daily BNP; pre-op TEE + intra-op TEE for surgical assessment; CTA reassessment if dissection
    inputs: lactate, tee
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence set + post-op surveillance scheduled
  11. 11FOLLOWUP
    Repeat TTE at 1 wk + 1 mo + 3 mo post-surgery for valve function + LV recovery; cardiac rehab; GDMT if persistent HFrEF; endocarditis prophylaxis per AHA 2007 if prosthetic valve; lifelong follow-up at valve clinic; long-term anticoagulation per valve type (mechanical = warfarin INR 2-3 aortic; bioprosthetic = ASA + 3 mo warfarin + ASA chronic); aortic surveillance imaging if dissection / connective tissue disease
    advance: Recovery echo, valve clinic follow-up, GDMT, long-term anticoag, aortic surveillance plan booked