This handout is for cardiogenic shock — acute severe mitral regurgitation. Your care team identified this based on: sudden flash pulmonary edema + hemodynamic deterioration → acute severe mr with cs until proven otherwise.
Other reasons your team may use this plan: stat tee: ruptured papillary muscle / flail leaflet / vena contracta ≥0.7 cm / eroa ≥0.4 cm² + biventricular dysfunction + shock physiology; recent inferior / inferoposterior mi (24-168 h prior) + new harsh holosystolic murmur at apex + flash pulmonary edema → posteromedial papillary muscle rupture; active infective endocarditis (s. aureus, streptococcus) + acute hemodynamic deterioration + new mitral regurgitation → leaflet perforation / chordal destruction.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| norepinephrine | 0.05–0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — NE first-line in CS; CAUTION — pair with afterload reduction in acute MR to prevent worsening regurgitant fraction |
| dobutamine | 2.5 µg/kg/min CAUTIOUS titration | IV | continuous | DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in acute MR (may worsen MR severity by increasing LV contractility) |
| sodium nitroprusside | 0.25–0.5 µg/kg/min start; titrate to MAP 65–75 | IV | continuous | Cornerstone afterload reduction in acute severe MR — reduces regurgitant fraction + improves forward flow + reduces pulmonary edema; cyanide accumulation risk if eGFR <30 |
| nitroglycerin | 5–20 µg/min titrate up to 200 µg/min | IV | continuous | Preload reduction → reduces PCWP + V-wave + pulm edema; first-line decongestant in acute MR with preserved MAP |
| furosemide | 40–80 mg IV bolus then infusion 5–10 mg/h | IV | bolus + continuous | Decongest after perfusion stable (ESC 2021 HF Guidelines); continuous infusion preferred for refractory pulm edema |
| vasopressin | 0.03 U/min fixed | IV | continuous | V1-mediated; pulmonary-vascular sparing; adjunct to NE when acute MR + RV failure overlap |
| vancomycin | 25–30 mg/kg IV load then 15–20 mg/kg q12h adjusted to trough 15–20 | IV | q12h | AHA 2015 endocarditis guideline empiric coverage for native valve endocarditis — gram-positive cocci dominant pathogen spectrum |
| ceftriaxone | 2 g IV q24h | IV | q24h | AHA 2015 endocarditis guideline empiric coverage — covers Streptococcus + HACEK organisms |
| warfarin | Post-op: 5 mg daily; mechanical mitral INR target 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA | PO | daily | ACC/AHA 2020 valvular Class I — mechanical mitral valve requires lifelong warfarin INR 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA chronic |
Plan: Acute severe MR + CS — emergent surgery + IABP bridge (preferred MCS) + cautious inotrope + diuretic + afterload reduction; AVOID isolated vasoconstrictor
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Repeat TTE at 1 wk + 1 mo + 3 mo post-surgery for valve function + LV recovery; cardiac rehab; the four foundational heart-failure medications 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)
Guideline: Otto et al ACC/AHA 2020 valvular heart disease guideline (PMID 33342587); Vahanian ESC 2021 valvular heart disease (PMID 34453165); Estévez-Loureiro JACC 2024 IREMMI registry — MitraClip in acute MR with CS (PMID 36440867); SCAI 2022 CS staging (Naidu PMID 35718438)