Early management of acute aortic and mitral regurgitations in the intensive care unit

Abstract

Acute pulmonary edema is the most frequent presentation of aortic (AR) and mitral (MR) regurgitation in the intensive care unit (ICU). The etiologic diagnosis is performed using transthoracic echocardiography and mainly transesophageal echocardiography (TEE). The aim of the medical management in ICU is to stabilize the hemodynamic status of the patient before the surgical treatment, in the absence of major comorbidities. Timing of surgery depends on the response to the optimal medical treatment. It consists in a valve replacement with a bioprosthesis or a mechanical prosthesis or in a mitral valve repair. Acute type A aortic dissection is one of the etiologies of acute AR. Rupture of the ascending aorta is at the first line and severely impairs the final outcome. In the situation of an ischemic MR, management also includes myocardial revascularization. Infective endocarditis (IE) is responsible of the majority of the AR and MR in the ICU. TEE for the diagnosis is mandatory. Antibiotics represent the first line of the optimal medical treatment. Urgent valve surgery is indicated when regurgitation leads to acute heart failure. Early surgical treatment decreases the risk of embolic events, local extension and improves survival rate. Only hemorrhagic brain stroke could postpone surgery due to the risk of intra-cerebral bleeding induced by extracorporeal circulation. Prognosis of AR and MR is worse when caused by IE, and even more severe in case of IE on a prosthetic valve. A multidisciplinary team approach should improve the survival rate in ICU patients admitted with AR and MR-related morbidities.