Patients experiencing cardiogenic shock due to severe aortic stenosis (AS-CS) face significantly higher mortality rates, but early aortic valve replacement shows promise in improving outcomes, according to a retrospective study from the Cleveland Clinic published in the Journal of the American Heart Association. The research highlights the limitations of medical management and balloon aortic valvuloplasty (BAV) while emphasizing the benefits of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).
The study, led by Grant Reed, MD, MSc, analyzed data from 2,737 adults admitted to Cleveland Clinic’s cardiac intensive care unit with cardiogenic shock between 2010 and 2021, identifying 199 patients (7.3%) with AS-CS. The findings revealed that patients with AS-CS had a significantly higher 30-day mortality rate compared to those with cardiogenic shock alone (30% vs. 20%, P = .0011).
Treatment Modalities and Mortality
Among AS-CS patients, the 30-day mortality rate was considerably higher in those receiving medical management (50%) compared to those undergoing transcatheter or surgical interventions (18% and 16%, respectively, P < .001). While in-hospital mortality rates were similar between TAVR and BAV, a significant divergence emerged by 30 days, with BAV associated with a 26% mortality rate versus 4% with TAVR (P = .04). The mortality rate with BAV increased to approximately 50% by 90 days, approaching the rate observed with medical management.
The Role of Balloon Aortic Valvuloplasty
"Clearly the effects of balloon aortic valvuloplasty diminish over time if it is not followed by more definitive management," Dr. Reed noted. He suggested that BAV could serve as a reasonable initial step for stabilizing critically ill patients when SAVR and TAVR are not immediately feasible. "This can be particularly helpful if the cause of cardiogenic shock is uncertain and it’s not clear if valve replacement would alter the treatment course," Dr. Reed explained. "If the patient responds well and their underlying illness can be improved, then definitive valve replacement can be offered."
Adjusted Outcomes and Long-Term Benefits
Multivariable regression analysis revealed that medical management was associated with a significantly elevated 30-day mortality risk (HR = 3.69; 95% CI, 2.04-6.66), while transcatheter (HR = 0.30; 95% CI, 0.15-0.59) and surgical (HR = 0.23; 95% CI, 0.10-0.54) management significantly reduced this risk. At one year, medical management continued to show significantly higher risk compared to SAVR or TAVR (P < .0001 for both).
Clinical Implications and Future Directions
The study underscores the importance of considering aortic valve replacement for patients with cardiogenic shock due to aortic stenosis. Anthony Zaki, MD, a Cleveland Clinic cardiothoracic surgeon, emphasized that "aortic valve replacement is a highly effective treatment for cardiogenic shock due to aortic stenosis, as it relieves obstruction, offloads the left ventricle and restores forward flow." He added that surgery allows for simultaneous correction of other associated conditions, such as coronary artery disease, mitral regurgitation, and atrial fibrillation, offering a comprehensive approach to patient care.
