Chapter 12 / Percutaneous Valvuloplasty 187
This is of particular interest during pregnancy. In such cases, even if the initial
results are suboptimal, PMC can be a useful life-saving procedure and serves as a
bridge to lower-risk secondary surgery. In the elderly population, the decision is
much more difficult because data are lacking (27). Some offer PMC despite the high
risk because unexpected good results may be obtained and individual results remain
largely unpredictable (16). The objective here is to obtain, at best, a modest
improvement in life expectancy. We favor an individualized approach, taking into
account the multifactorial nature of the prediction of the results of PMC. The proce-
dure should not be performed in elderly patients at the end stage of the disease,
where all the predictors of poor results (6,7), both anatomic and clinical, are present.
Here, the procedure is highly likely to be unsuccessful, the risk is very high, and sec-
ondary surgery cannot be considered. In contrast, PMC seems to be a useful, even if
palliative treatment, as a bridge to surgery in patients with unfavorable anatomy if
all other characteristics are favorable (28).
AORTIC STENOSIS
Severe aortic stenosis is the most frequent valve disease in Western countries. It is now
mostly degenerative in origin and affects elderly patients. The occurrence of cardiogenic
shock in aortic stenosis is rare but associated with catastrophic consequences (29).
Clinical Presentation of Cardiogenic Shock
In patients with severe aortic stenosis, cardiogenic shock may occur at the end stage of
the disease. The condition may deteriorate continuously or be precipitated by a complica-
tion that may be cardiac, such as atrial fibrillation or acute myocardial infarction, noncar-
diac (e.g., a respiratory infection), or a complication of an invasive examination (30).
Aortic stenosis can result in cardiogenic shock based on other causative factors,
such as left ventricular failure resulting from excessively high wall stress and afterload
mismatch or more severe left ventricular failure despite less severe aortic stenosis (31),
associated coronary artery disease leading to acute myocardial infarction (32), or
ischemic cardiomyopathy. Furthermore, hypotension and/or coronary disease could
initiate a vicious circle of myocardial ischemia, leading to an exacerbation of left ven-
tricular dysfunction, which could further reduce myocardial perfusion and increase
myocardial ischemia. As an illustration, 52% of the patients in the largest series of
PAV for cardiogenic shock had non-Q myocardial infarction at admission (33).
Finally, aortic stenosis may be discovered only at the onset of shock or after cardiac
arrest, the diagnosis being made by echocardiography or suggested by the presence of
valvular calcification.
Results of Percutaneous Aortic Valvuloplasty
Aortic stenosis complicated by cardiogenic shock is a rare clinical situation. In large
series of PAV (33,34), patients with shock account for only 6% of cases. The results in
this specific subgroup have been described only in short series (33–37) and a few case
reports (38–41) (Table 3). The largest series included 21 patients with strict criteria for
shock (33), whereas that by Cribier in which the criteria for shock were less precisely
defined (37), included 10 patients. Contrary to mitral stenosis, the patients included in
these series were almost exclusively elderly with severe comorbidities.
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