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

Cardiogenic shock — acute severe mitral regurgitation

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to acute severe mitral regurgitation with cardiogenic shock per Otto ACC/AHA 2020 valvular heart disease guideline (PMID 33342587) + Vahanian ESC 2021 valvular (PMID 34453165). Etiology spectrum: papillary muscle rupture (post-MI, classically inferior MI rupturing posteromedial PM via single PDA blood supply, day 2-7 post-MI, mortality ≥80% medical vs <10% surgical per Thompson SHOCK 2000); chordal rupture (degenerative MVP, endocarditis); valve perforation (S. aureus / Streptococcus endocarditis); blunt chest trauma; iatrogenic (TAVR / MitraClip / valvuloplasty). Hemodynamics CRITICAL: low CO + HIGH PCWP with prominent V-wave + flash pulmonary edema; LV unable to compensate (no chronic remodeling like chronic MR); CXR shows flash pulm edema with NORMAL cardiac silhouette (cardinal differentiator from chronic decompensated MR). Diagnosis: STAT TEE is the diagnostic anchor — PISA jet, vena contracta ≥0.7 cm, EROA ≥0.4 cm², regurgitant volume ≥60 mL, ruptured papillary muscle / leaflet visualization; ECG (territory of MI); CXR (flash edema + normal heart size); PA catheter (large V-wave on PCWP tracing). Treatment ACUTE: EMERGENT SURGICAL MV repair / replacement is definitive (Class I per ACC/AHA 2020); IABP is the PREFERRED MCS bridge (off-loads LV + reduces MR severity — favourable physiology in MR opposite to AR); inotrope (dobutamine) CAUTIOUS (may worsen MR by increasing LV contractility); diuretic + nitroprusside / nitrate to reduce preload + afterload; AVOID isolated vasoconstrictor (worsens regurgitant fraction); intubation often needed for refractory pulm edema; TEER (MitraClip) salvage option for prohibitive surgical risk per Estévez-Loureiro IREMMI 2024 (PMID 36440867); empiric vancomycin + ceftriaxone if endocarditis suspected per AHA 2015. Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for acute MR — IABP-preferred MCS, emergent surgery, paired afterload reduction with NE, TEER salvage option, CT surgery activation from minute 0. 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 flash pulmonary edema + hemodynamic deterioration → acute severe MR with CS until proven otherwise
    sudden_flash_pulmonary_edema_with_cardiogenic_shock
  • imaging
    STAT TEE: ruptured papillary muscle / flail leaflet / vena contracta ≥0.7 cm / EROA ≥0.4 cm² + biventricular dysfunction + shock physiology
    tee_papillary_muscle_rupture_or_flail_leaflet
  • history
    Recent inferior / inferoposterior MI (24-168 h prior) + new harsh holosystolic murmur at apex + flash pulmonary edema → posteromedial papillary muscle rupture
    recent_inferior_mi_with_new_holosystolic_murmur
  • symptom
    Active infective endocarditis (S. aureus, Streptococcus) + acute hemodynamic deterioration + new mitral regurgitation → leaflet perforation / chordal destruction
    acute_endocarditis_with_decompensation
  • history
    Recent blunt chest trauma (steering wheel, fall) + new murmur + hemodynamic compromise → traumatic mitral leaflet tear / papillary avulsion
    recent_chest_trauma_with_cardiogenic_shock

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Older patients (post-MI papillary rupture, degenerative MVP) over-represented; informs surgical-risk stratification + TEER candidacy
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; gates vasopressor escalation; SBP <90 with flash pulm edema is the cardinal acute MR + CS presentation
  • hrrequired
    vital • used at CONTEXT
    Sinus tachycardia maintains compensatory forward flow; AF / new arrhythmia worsens hemodynamics by losing atrial contribution and shortening diastolic filling
  • spo2required
    vital • used at INITIAL_WORKUP
    Flash pulmonary edema severity tracker; intubation often needed
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Elevated if etiology is post-MI papillary rupture; trend tracks ongoing ischemia
  • 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 diuretics + nitrate; contrast nephropathy risk for cath/CTA
  • blood_culturesrequired
    lab • used at INITIAL_WORKUP
    Active endocarditis is a major etiology of acute MR; obtain × 3 sets before any antibiotics
  • echorequired
    imaging • used at INITIAL_WORKUP
    Bedside TTE for initial screen — flail leaflet, eccentric jet, biventricular function; PRELIMINARY only — TEE is gold standard
  • teerequired
    imaging • used at BRANCHING_WORKUP
    GOLD STANDARD — ruptured papillary muscle visualization, vena contracta ≥0.7 cm, EROA ≥0.4 cm², regurgitant volume ≥60 mL, mechanism (rupture vs perforation vs flail), surgical planning
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Recent or active inferior / inferoposterior MI (papillary rupture); AF; LV strain pattern
  • cor_angiorequired
    imaging • used at BRANCHING_WORKUP
    Coronary angiography for ischemic etiology — culprit lesion identification + revascularization assessment if MI-related papillary rupture
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Flash pulmonary edema with normal-sized cardiac silhouette is cardinal differentiator from chronic decompensated MR
  • recent_mirequired
    history • used at CONTEXT
    Day 2-7 post-MI is highest risk window for papillary muscle rupture; inferior MI ruptures POSTEROMEDIAL PM (single PDA blood supply)
  • mvp_history
    history • used at CONTEXT
    Pre-existing degenerative MVP predisposes to spontaneous chordal rupture
  • recent_chest_trauma
    history • used at CONTEXT
    Blunt chest trauma → leaflet tear / papillary avulsion
  • recent_valve_intervention
    history • used at CONTEXT
    Recent TAVR / MitraClip / balloon valvuloplasty / surgical valve manipulation

12-phase flow (11)

  1. 1FRAME
    Confirm acute severe MR as the cardiogenic shock etiology — sudden flash pulm edema + new holosystolic murmur + biventricular dysfunction; identify suspected sub-etiology (post-MI papillary rupture vs chordal rupture vs endocarditis vs trauma vs iatrogenic) which drives surgical urgency
    inputs: echo, cxr
    advance: Acute severe MR confirmed and sub-etiology hypothesis stated
  2. 2ENTRY
    CS team activation INCLUDING cardiothoracic surgery from minute 0 — mortality ≥80% medical vs <10% surgical for papillary rupture; mobilize STAT TEE; mobilize cath lab if MI-related; mobilize MCS team (IABP preferred bridge in acute MR)
    inputs: sbp, lactate
    advance: CS team + cardiothoracic surgery + STAT TEE + MCS team activated
  3. 3CONTEXT
    Recent MI timing (day 2-7 highest risk for PM rupture), endocarditis exposure, MVP history, recent trauma, recent valve intervention, allergies, code status
    inputs: hr, creatinine, recent_mi, mvp_history
    advance: Context complete and sub-etiology working hypothesis stated
  4. 4RED_FLAGS
    Pre-arrest physiology, refractory pulmonary edema requiring intubation (very common), papillary muscle rupture confirmed on TEE → emergent surgery, refractory shock despite IABP → escalate to advanced MCS / surgery
    inputs: sbp, spo2
    actions: acute_valvular_emergency, cardiogenic_shock
    advance: Mechanical emergency screened and surgery activated if PM rupture
  5. 5INITIAL_WORKUP
    ECG (territory of MI), bedside echo (flail leaflet), troponin, BNP, BMP, lactate, blood cultures × 3, CXR (flash edema + normal cardiac silhouette), CBC, coags
    inputs: ecg, echo, troponin, 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 + surgical planning (PISA, vena contracta, EROA, regurgitant volume); coronary angiography if MI-related (culprit lesion + revasc planning); CT if dissection or trauma suspected; PA catheter for V-wave + PCWP
    inputs: tee, cor_angio
    actions: acs_pathway
    advance: Mechanism confirmed by TEE + surgical plan documented
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication; surgical-risk stratification (STS / EuroSCORE) for TEER vs surgical decision; sub-etiology drives prognosis (papillary rupture mortality ≥80% medical, <10% surgical per Thompson SHOCK; endocarditis with active sepsis higher operative mortality)
    inputs: sbp, lactate, troponin
    advance: Risk stratified, surgical candidacy assessed, TEER decision documented if prohibitive risk
  8. 8TREATMENT
    EMERGENT SURGICAL MV repair / replacement (Class I per ACC/AHA 2020); IABP bridge (off-loads LV, REDUCES MR severity — preferred MCS in acute MR); diuretic + nitroprusside / nitrate to reduce preload + afterload; dobutamine cautious (may worsen MR); NE only when needed for MAP ≥65 paired with afterload reduction; AVOID isolated vasoconstrictor; intubation often needed for pulm edema; TEER (MitraClip) salvage option for prohibitive surgical risk per Estévez-Loureiro IREMMI 2024 (PMID 36440867); empiric antibiotics if endocarditis suspected (vanc + ceftriaxone)
    inputs: sbp, lactate
    actions: acute_valvular_emergency
    advance: Surgical or TEER plan active + IABP placed if available + appropriate pharmacologic support running
  9. 9DISPOSITION
    Direct OR transfer for emergent valve surgery (Class I); if unstable, IABP bridge in CICU 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, IC, advanced HF, ID if endocarditis)
  10. 10MONITORING
    A-line, central line, PA catheter for PCWP + V-wave trend, lactate clearance, urine output; continuous telemetry; serial echo q12-24h post-surgery for valve function + LV recovery; daily BNP
    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 per type; bioprosthetic = ASA + 3 mo warfarin + ASA chronic)
    advance: Recovery echo, valve clinic follow-up, GDMT, long-term anticoag plan booked