Author: Dr. Catherine Buckley
When I think of patients with valvular disease in the setting of the emergency department, it is frequently the acute on chronic picture. For instance: the Aortic stenosis patient with significant worsening of their fluid overload symptoms because of sepsis. What I typically don’t imagine is diagnosing or treating brand new valvular emergencies. Thank goodness for didactics! We are going to briefly review acute Mitral Regurgitation and acute Aortic regurgitation based on a wonderful talk given by Dr. Yelena Dukarevich.
Acute Mitral Regurgitation
Acute Mitral regurgitation (unlike it’s chronic compatriot) is a medical and surgical emergency. Up until now their left atrium has not had to compensate for the back-flow of so much blood, so it isn’t all dilated and stretchy as you may see in the chronic version. Because of this blood just backs up further and further into the lungs. Furthermore, as nature likes to follow the path of least resistance- these patients are losing a lot of their cardiac output; much of the stroke volume is lost back through the mitral valve. As their cardiac output tries to make up for their loss of stroke volume, heart rate will likely increase. With the back-flow, these patients are going to present in florid heart failure with acute onset dyspnea and fluid overload. And they may possibly already be in shock.
Things to look for in the history to help you decipher out this scary presentation include → MI 2-7 days ago (papillary muscle rupture), Endocarditis, takosubo cardiomyopathy, or blunt chest trauma (papillary muscle or chordae tendineae rupture from elevated Ventricular pressures during the event, which is rare). (McDonald et al.) These patient’s will likely need operative repair, so get your thoracic surgeons on board soon. In the meantime, you can help them symptomatically, give BIPAP or Nitrates for fluid overload, Dobutamine for shock, etc.
Acute Aortic Regurgitation
Another valve requiring urgent operative repair when acutely regurg-ing is the aortic valve. This can happen acutely in the setting of Endocarditis, Aortic dissection, and again blunt chest wall trauma (same etiology but the most common valve injured.) (Hamirani et al. ) Aortic regurg becomes emergent in an acute setting as the back-flow of blood into the left ventricle during diastole prevents forward flow from the left atrium, because again the heart has not had the years to dilate.
This of course causes a significant drop in cardiac output and patients will present with similar symptoms as acute mitral regurg: dyspnea, fluid overload, tachyardia, cardiogenic shock. However, your job of medical management in the ED will be a wee bit different. As the issue is that not enough fluid is getting into the left ventricle in the correct direction- this makes it preload dependent. So Nitrates will not work well for you. You can still start the patient on Bipap to help them breathe… important, I guess… And you can still give Dobutamine. Definitely still get those surgeons on board soon.
One thing to keep in mind- though we like to normalize vitals to make us feel better about the patient- the tachycardia that these patients have is compensatory. It is helping them have some sort of a cardiac output. So don’t give them Beta-blockers as we don’t want to cheat them of this.
Conclusion
These vavular emergencies can hide easily; they are often diagnosed instead as sepsis, pneumonia or simple heart failure. (Hamirani et al. ) Bedside ECHO, if available, can be extremely valuable, especially in the context of the above histories or with other concerning findings (i.e. new murmur.) Definitely make sure you add these to your differential and be aware that- though not emergent in the chronic versions- acute mitral and aortic valve regurgitation are life threatening!
Citation
- Hamirani, Y. Dietl, C. Voyles, W. Peralta, M. Begay, D. Raizada, V. Acute aortic regurg. Circulation. 2012; 126: 1121-1126
- McDonald, M. Orszulak, T. Bannon, M. Zietlow, S. Mitral valve injury after blunt chest trauma. Annals of Thoracic Surgery. 1996; 61:1024-1029
- Special Thanks to Dr. Yelena Dukarevich for teaching us this information, making the trek out to us, and for dealing so effortlessly with faulty technology while doing all the above!