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cardio.cardiogenic-shock.acute-mr-endocarditis.v1

Cardiogenic shock — acute severe MR from infective endocarditis

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Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed specifically to acute severe MR driven by INFECTIVE ENDOCARDITIS per Baddour AHA 2015 (PMID 26373316) + Delgado ESC 2023 update (PMID 37622660) + Otto ACC/AHA 2020 valvular (PMID 33342587). Distinguished from cardio.cardiogenic-shock.acute-mitral-regurgitation.v1 (full etiology spectrum) by IE-specific focus + concurrent sepsis management + antibiotic + source control imperatives. Pathophysiology: Vegetation-mediated leaflet perforation, chordal destruction, ring abscess extension → ACUTE SEVERE MR + flash pulm edema + cardiogenic shock; CONCURRENT SEPSIS → distributive shock overlay + multi-organ dysfunction (AKI, hepatic dysfunction, coagulopathy, encephalopathy); septic emboli → stroke, splenic / renal infarcts, mycotic aneurysms. Diagnosis: STAT TEE (vegetations, leaflet defect, regurgitation severity, ring abscess); BLOOD CULTURES × 3 from separate sites BEFORE antibiotics; modified Duke criteria; cardiac CT for perivalvular extension; CT brain for septic emboli; cardiac MRI optional. Treatment ACUTE: IV antibiotics IMMEDIATELY post-cultures (vanc 25-30 mg/kg load + ceftriaxone 2 g IV q24h empiric → tailor to organism); EMERGENT SURGERY (Class I per ACC/AHA 2020 valvular if HF + uncontrolled infection + abscess; do NOT delay surgery for prolonged antibiotic course in active IE with HF — Wang JAMA 2014 PMID 24247733); IABP bridge to surgery (preferred MCS in acute MR); diuretic + nitroprusside / nitrate; cautious dobutamine; AVOID isolated vasoconstrictor; intubation often needed; SOURCE CONTROL critical (remove infected lines, CIED extraction per HRS 2017, dental clearance); TEER salvage option for prohibitive surgical risk per Estévez-Loureiro IREMMI 2024 (PMID 36440867). Postop: prolonged IV antibiotic course (4-6 weeks total native; 6 weeks + rifampin/gentamicin prosthetic per AHA 2015); follow-up TEE; long-term valve management (anticoagulation per valve type); endocarditis prophylaxis education (AHA 2007); addiction medicine if IVDU. Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for IE-driven acute MR — antibiotic + source control + sepsis bundle + emergent surgery + IABP-preferred MCS + lifelong IE prophylaxis education + addiction medicine if IVDU. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 20 IE-specific acute valvular variant.

Entry points (5)

  • symptom
    Fever + new harsh holosystolic murmur at apex + flash pulmonary edema + hemodynamic deterioration → IE-driven acute severe MR with CS until proven otherwise
    fever_with_new_holosystolic_murmur_and_flash_pulmonary_edema
  • imaging
    STAT TEE: mitral valve vegetation ≥10 mm + leaflet perforation / chordal destruction + acute severe MR (vena contracta ≥0.7 cm, EROA ≥0.4 cm²) + biventricular dysfunction + shock physiology
    tee_vegetation_with_leaflet_perforation
  • history
    Positive blood cultures (S. aureus, Streptococcus viridans, enterococcus) + sudden cardiac decompensation → acute MR from leaflet perforation / chordal destruction
    positive_blood_cultures_with_sudden_decompensation
  • history
    IV drug use history + new fever + acute heart failure + new murmur → left-sided IE with acute MR (less common than right-sided IVDU IE but higher mortality)
    iv_drug_use_with_acute_heart_failure_and_fever
  • history
    Prosthetic mitral valve + new fever + new murmur + paravalvular leak / dehiscence on TEE → prosthetic valve IE with acute severe MR (high mortality, requires surgery)
    prosthetic_valve_with_fever_and_decompensation

Required inputs (24)

  • agerequired
    demographic • used at CONTEXT
    Older patients higher operative risk; younger IVDU patients distinct demographic; informs surgical-risk stratification + TEER candidacy
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; SBP <90 + flash pulm edema + fever = IE-driven acute MR with CS / sepsis overlap
  • hrrequired
    vital • used at CONTEXT
    Sinus tachycardia + fever (sepsis); new AV block raises perivalvular abscess concern (esp with aortic IE extending to AV groove)
  • temperaturerequired
    vital • used at CONTEXT
    Fever supports IE; afebrile presentation possible in subacute IE / immunocompromised / prior antibiotics
  • spo2required
    vital • used at INITIAL_WORKUP
    Flash pulmonary edema severity tracker; intubation often needed
  • blood_culturesrequired
    lab • used at INITIAL_WORKUP
    FOUNDATIONAL — three sets from separate sites BEFORE antibiotics; modified Duke criteria major criterion; drives organism-specific antibiotic regimen
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis with left shift in acute IE; anemia / hemolysis (mechanical hemolytic anemia from regurgitant jet); thrombocytopenia in sepsis
  • inflammatory_markersrequired
    lab • used at INITIAL_WORKUP
    CRP + ESR support IE diagnosis (modified Duke minor criterion); trend therapeutic response
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Elevated if myocardial extension / septic emboli / type 2 MI; trends 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 + sepsis severity; CardShock prognostication (Harjola EHJ 2015 PMID 26333869); SSC 2021 sepsis bundle
  • creatininerequired
    lab • used at CONTEXT
    AKI from sepsis + low forward flow + nephrotoxic antibiotics (vancomycin, gentamicin); contrast nephropathy risk for cath/CTA
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Hematuria + proteinuria (immune-mediated glomerulonephritis from IE); modified Duke minor criterion
  • echorequired
    imaging • used at INITIAL_WORKUP
    Bedside TTE for initial screen — flail leaflet, vegetation, biventricular function; PRELIMINARY only — TEE is gold standard for IE
  • teerequired
    imaging • used at BRANCHING_WORKUP
    GOLD STANDARD for IE — vegetation visualization (size + mobility), leaflet defect / perforation, regurgitation severity (PISA, vena contracta, EROA), ring abscess (perivalvular extension), prosthetic dehiscence
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Sinus tachy / AF; new AV block raises perivalvular abscess concern (esp aortic root abscess extending to AV groove)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Flash pulmonary edema with normal-sized cardiac silhouette; septic emboli appear as wedge-shaped infarcts (right-sided IE) or peripheral nodules
  • cardiac_ct
    imaging • used at BRANCHING_WORKUP
    Perivalvular abscess / fistula characterization (better than TEE for some abscess locations); coronary angiography substitute pre-op (avoids embolization risk of cath in active IE)
  • ct_brainrequired
    imaging • used at BRANCHING_WORKUP
    Septic emboli to brain (stroke, mycotic aneurysm) — common in left-sided IE; impacts surgical timing (delay if hemorrhagic stroke)
  • iv_drug_userequired
    history • used at CONTEXT
    Major IE risk factor (right-sided IE more common but left-sided also occurs); high re-IE rate without addiction treatment
  • prosthetic_valverequired
    history • used at CONTEXT
    Prosthetic valve IE has higher mortality + requires surgery + extended antibiotic course (6 wk + rifampin/gentamicin per AHA 2015)
  • cied_history
    history • used at CONTEXT
    CIED (pacemaker / ICD) lead infection / vegetation requires device extraction per HRS 2017 expert consensus
  • recent_dental_or_surgical_procedure
    history • used at CONTEXT
    Bacteremia risk; helps identify portal of entry (helps source control)
  • penicillin_allergyrequired
    history • used at CONTEXT
    Drives empiric antibiotic selection — vanc + cefepime alternative if severe penicillin/cephalosporin allergy precludes ceftriaxone

12-phase flow (11)

  1. 1FRAME
    Confirm IE-driven acute severe MR as the cardiogenic shock etiology — fever + new holosystolic murmur + flash pulm edema + hemodynamic deterioration in patient with IE risk factors (IVDU, prosthetic valve, CIED, indwelling line, prior IE); identify mechanism (leaflet perforation vs chordal destruction vs ring extension)
    inputs: echo, temperature
    advance: IE-driven acute MR confirmed as working diagnosis with mechanism stated
  2. 2ENTRY
    CS team activation INCLUDING cardiothoracic surgery + ID team from minute 0; mortality high without timely surgery; mobilize STAT TEE; mobilize cath lab if MI overlap; mobilize MCS team (IABP preferred bridge in acute MR); SEPSIS BUNDLE simultaneously
    inputs: sbp, lactate, temperature
    advance: CS team + cardiothoracic surgery + ID + STAT TEE + MCS team + sepsis bundle activated
  3. 3CONTEXT
    IV drug use (high re-IE rate without addiction treatment), prosthetic valve, CIED, indwelling lines, recent dental / surgical procedures, immunocompromise, allergies (drives empiric antibiotic), code status
    inputs: hr, creatinine, iv_drug_use, prosthetic_valve, cied_history, penicillin_allergy
    advance: Context complete and risk-factor profile + portal of entry working hypothesis stated
  4. 4RED_FLAGS
    Pre-arrest physiology, refractory pulm edema requiring intubation (very common), ring abscess / heart block on ECG / TEE → emergent surgery, septic emboli causing stroke (esp hemorrhagic), refractory shock despite IABP → escalate to advanced MCS / surgery, perivalvular abscess on TEE → emergent surgery
    inputs: sbp, spo2
    actions: acute_valvular_emergency, cardiogenic_shock
    advance: Mechanical + infectious emergencies screened and surgery activated if criteria met
  5. 5INITIAL_WORKUP
    BLOOD CULTURES × 3 BEFORE antibiotics (foundational), ECG, bedside echo, troponin, BNP, BMP, lactate, CBC, CRP/ESR/PCT, urinalysis, CXR, ABG, coags
    inputs: ecg, echo, troponin, bnp_ntprobnp, lactate, blood_cultures, cxr, cbc, inflammatory_markers, urinalysis
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg, panel.coag
    advance: Workup complete + cultures drawn + empiric antibiotics started + SCAI stage assigned
  6. 6BRANCHING_WORKUP
    STAT TEE — gold standard mechanism + severity + vegetation + abscess + surgical planning; cardiac CT if perivalvular extension suspected; CT brain (septic emboli + stroke + mycotic aneurysm); abdominal CT if splenic / renal infarcts suspected; PA catheter for V-wave + PCWP; coronary angiography pre-op (or CT-coronary if cath embolization concerns)
    inputs: tee, ct_brain
    advance: Mechanism confirmed by TEE + abscess characterized + embolic complications screened + surgical plan documented
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication; modified Duke criteria (definite vs possible IE); EuroSCORE / STS for surgical-risk stratification; sepsis severity (SOFA, qSOFA); concurrent stroke (delays surgery)
    inputs: sbp, lactate, troponin
    advance: Risk stratified + IE definite/possible + surgical candidacy assessed + stroke risk evaluated
  8. 8TREATMENT
    IV ANTIBIOTICS IMMEDIATELY post-cultures (vanc 25-30 mg/kg load + ceftriaxone 2 g IV q24h empiric; tailor to organism); EMERGENT SURGERY (Class I per ACC/AHA 2020 valvular if HF + uncontrolled infection + abscess); IABP bridge to surgery (preferred MCS in acute MR); diuretic + nitroprusside / nitrate (afterload reduction); cautious dobutamine; NE only when needed for MAP ≥65 paired with afterload reduction; AVOID isolated vasoconstrictor; intubation often needed; SOURCE CONTROL (remove infected lines, CIED extraction per HRS 2017); TEER (MitraClip) salvage option for prohibitive surgical risk per Estévez-Loureiro IREMMI 2024 (PMID 36440867)
    inputs: sbp, lactate
    actions: acute_valvular_emergency
    advance: Empiric antibiotics started + surgical or TEER plan active + IABP placed if available + source control initiated
  9. 9DISPOSITION
    Direct OR transfer for emergent valve surgery (Class I per ACC/AHA 2020 + ESC 2023); if unstable, IABP bridge in CICU then OR; advanced HF / transplant capable + IE-experienced center if not local; CICU at MCS-capable + IE-experienced center if non-operative bridge
    advance: Disposition assigned with MDT mobilised (cards, CT surgery, IC, advanced HF, ID, neurology if stroke)
  10. 10MONITORING
    A-line, central line, PA catheter for PCWP + V-wave trend, lactate clearance, urine output; continuous telemetry; serial blood cultures (sterilization tracking); serial echo q12-24h post-surgery for valve function + LV recovery; daily BNP + inflammatory markers + troponin; weekly LFT + CBC for antibiotic toxicity
    inputs: lactate, tee
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence set + post-op + sterilization surveillance scheduled
  11. 11FOLLOWUP
    Repeat TTE / TEE at 1 wk + 1 mo + 3 mo + 6 mo + annually post-surgery; complete prolonged IV antibiotic course (4-6 weeks for native valve, 6 weeks + rifampin/gentamicin for prosthetic valve per AHA 2015); cardiac rehab; GDMT if persistent HFrEF; endocarditis prophylaxis per AHA 2007 (lifelong for prosthetic valves, prior IE, congenital heart disease); long-term anticoagulation per valve type; addiction medicine follow-up if IVDU; dental clearance + planned dental work; lifelong follow-up at valve / IE clinic
    advance: Recovery echo, IE/valve clinic follow-up, GDMT, long-term anticoag plan, addiction medicine if IVDU, prophylaxis education booked