Chapter 11 / Cardiogenic Shock and Valvular Heart Disease 175
biological valve. It may show valve calcification, but not its hemodynamic conse-
quences. It may also show significant rocking of the base of the valve in cases of dehis-
cence, but color-Doppler will provide much more comprehensive data.
Patients with cardiogenic shock attributable to structural dysfunction of a biological
prosthetic valve should undergo emergency surgery. Until then, they should be given
supportive therapy. In a series of 400 patients who required reoperation for degenerated
bioprostheses, 153 (38%) were nonelective, including 4 (1%) urgent operations (121).
Using multivariable analysis, a nonelective surgery was a strong predictor of hospital
death and prolonged postoperative hospital stay.
Bioprosthetic valves may sometimes require replacement because of progressive
valve stenosis rather than regurgitation. The progression to stenosis is obviously slower
than regurgitation, which may occur or progress suddenly. The likelihood of presenting
in cardiogenic shock resulting from stenosed bioprosthetic valve is low. Therapy is
usually surgical. There are some reports on balloon valvuloplasty of stenosed biopros-
theses (133–138), but the results are less favorable than in native mitral valve valvulo-
plasty. Ex vivo and intraoperative studies showed that there is a high frequency of
dislodgment of friable fragments of calcific deposits and thrombi during inflation, dis-
lodgment of calcific deposits during insertion and withdrawal of the balloon, fracture
and dislodgment of portions of stiffened cusps (138), and high rate of severe valvular
regurgitation (137). The long-term results of a successful procedure are unknown.
In situ thrombosis may occur on top of a degenerated bioprosthetic valve. The
occurrence is low: In the series of Oliver et al., it was 10/161 (6.2%) among patients
with prosthetic valve malfunction (139). Two of these patients were operated, but eight
received anticoagulants and seven of them achieved long-term clinical and hemody-
namic improvement.
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