ICU Map

Acute Valvular Hemodynamic Collapse

Structured emergency bedside protocol from POCUS lesion differentiation to lesion-specific hemodynamics and surgical rescue.

RecognizeAssessDecideDifferentialInterveneReassess
New Murmur + Acute Pulmonary Edema or Shock
Assessment StepTrigger: Acute shock, flash pulmonary edema, or new cardiac murmurExplore Topic
Immediate bedside resuscitation: high-flow oxygen/intubation, arterial line placement, and norepinephrine for shock.
Assessment StepPerform Emergency Bedside Echocardiography (TTE / TEE)
Differentiate dominant valve pathology: Critical AS vs Acute MR vs Acute AR vs Prosthetic Valve Thrombosis.
Differential Branches (4)
1Branch
Decision PointCritical Aortic Stenosis (Vmax > 4 m/s, Mean Gradient > 40 mmHg)
Preload-dependent, non-compliant LV. Maintain high-normal SVR with phenylephrine/norepinephrine; maintain sinus rhythm 60–80 bpm; avoid inodilators.
Clinical ActionActivate Heart Valve Team: Urgent TAVR / SAVR or Bridge Balloon Valvuloplasty
Emergency transcatheter or surgical valve intervention for refractory cardiogenic shock.
2Branch
Decision PointAcute Severe Mitral Regurgitation (Flail Leaflet / Papillary Rupture / Giant v-waves)
Reduce afterload when blood pressure permits, support forward output with vasoactive/inotropic therapy when needed, and consider temporary mechanical circulatory support in selected shock phenotypes with structural-heart/cardiac-surgery input.
Clinical ActionEmergency Cardiac Surgery: Mitral Valve Repair or Replacement
Immediate operative repair for papillary muscle rupture or endocarditic destruction.
3Branch
Decision PointAcute Severe Aortic Regurgitation (Cusp Perforation / Aortic Dissection)
Urgent definitive valve/aortic management. While stabilizing, reduce afterload when blood pressure permits, support perfusion according to the shock phenotype, and avoid marked bradycardia. IABP can worsen significant aortic regurgitation and is contraindicated.
Clinical ActionEmergency Surgical Aortic Valve Replacement (SAVR) / Root Repair
Immediate surgery before irreversible myocardial distension and cardiac arrest occur.
4Branch
Decision PointObstructive Mechanical Valve Thrombosis (Loss of Clicks, High Gradient)
Evaluate surgical risk and thrombus size on TEE and cine-fluoroscopy.
Clinical ActionHeart Valve Team: Fibrinolysis vs Urgent Surgery
Choose fibrinolysis or surgery according to hemodynamic status, valve position, thrombus burden, bleeding/embolism risk, surgical risk, and local expertise. Low-dose slow/ultra-slow alteplase is one evidence-supported fibrinolytic strategy, not a universal default.

An educational representation of clinical reasoning, not a diagnostic algorithm or personalized medical advice — always apply clinical judgment and institutional protocols.

Caution

Escalate — Red Flags & Critical Warnings

  • IABP can worsen clinically significant aortic regurgitation by augmenting aortic diastolic pressure and regurgitant flow; moderate-to-severe AR is a contraindication.
  • Abrupt or excessive vasodilation in severe aortic stenosis can cause poorly tolerated hypotension and reduced coronary perfusion; titrate vasoactive therapy to the individual hemodynamic phenotype.

Related Bedside Clinical Problems (10)

Bedside Presentations
Sudden Hypoxemia

Bedside triage of acute desaturation: signal verification, immediate danger screening (DOPE / tension pneumothorax), oxygen escalation ladder, and mechanism-based differential.

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Acute Hypotension & Undifferentiated Shock

Rapid bedside hemodynamic categorization: confirming MAP < 65 mmHg, assessing peripheral perfusion, POCUS cardiac/IVC profiling, and differentiating hypovolemic, distributive, cardiogenic, and obstructive etiologies.

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Refractory Shock Despite High-Dose Vasopressors

Advanced multimodal hemodynamic rescue: second-line vasopressors (vasopressin, angiotensin II), inotropic augmentation, stress-dose steroids, metabolic correction, and mechanical circulatory support evaluation.

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Linked Deep-Dive Topics (6)

Reference Knowledge
Valvular Heart Disease & Infective Endocarditis in the ICUcardiovascular

Critical AS, acute AR/MR mechanics, prosthetic valve emergencies, and infective endocarditis with multidisciplinary surgical triggers.

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Cardiogenic Shockcardiovascular

Primary pump failure, SCAI staging (A–E), PAC hemodynamics (CPO, PAPi), inotrope selection, emergent revascularization, and mechanical circulatory support.

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Acute Heart Failure & Cardiogenic Congestioncardiovascular

Hemodynamic phenotypes (SCAPE vs ADHF vs Cardiogenic Shock), non-invasive positive pressure ventilation, high-dose vasodilator algorithms, loop diuretics, and sequential nephron blockade.

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Acute Aortic Syndromescardiovascular

Emergency classification, anti-impulse medical stabilization, and surgical vs endovascular management of aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer.

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Acute Coronary Syndromecardiovascular

Plaque rupture, coronary thrombosis, STEMI vs NSTEMI risk stratification, emergent reperfusion, DAPT/anticoagulation, and mechanical/electrical ICU complications.

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Acute Right Ventricular Failurecardiovascular

RV anatomy and ischemia spiral, ventricular interdependence (D-sign), echocardiographic metrics (TAPSE, S', PAPi, VExUS), and the 4-pillar resuscitation strategy.

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Evidence status

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