RECIPE FOR DISASTER: PROSTHETIC AORTIC VALVE FAILURE, BETA-BLOCKERS, AND CALCIUMCHANNEL BLOCKERS
Recommended Citation
Almajed M, Saleem A, Wexler B, Patton J, Villablanca PA, Rabbani B. RECIPE FOR DISASTER: PROSTHETIC AORTIC VALVE FAILURE, BETA-BLOCKERS, AND CALCIUMCHANNEL BLOCKERS. J Am Coll Cardiol 2024; 83(13):2996.
Document Type
Conference Proceeding
Publication Date
4-1-2024
Publication Title
J Am Coll Cardiol
Abstract
Background Beta-blocker (BB) therapy is discouraged in patients with AR as negative chronotropy prolongs diastole thereby increasing regurgitant volume. Coadministration of BB and nondihydropyridine calcium channel blocker (CCB) results in profound negative chronotropy causing symptomatic bradycardia and heart block. Treatment of BB and CCB toxicity includes intravenous fluids, atropine, glucagon, vasopressors, and inotropes. Case A 75-year-old man presented with syncope. His history was notable for CAD for which he underwent LCx stenting two weeks prior and IE for which he underwent SAVR. He had inadvertently taken higher doses of both BB and nondihydropyridine CCB an hour before symptom onset. He was found to be hypothermic, bradycardic, and in undifferentiated shock that did not respond to initial resuscitation. Due to concern for medication overdose, he was treated with atropine, glucagon, and calcium with minimal response; initiation of continuous epinephrine resolved his shock state. Upon reevaluation, he reported exertional dyspnea and was noted to have an early diastolic murmur. Echocardiogram revealed severe insufficiency of the prosthetic aortic valve (AV) with a flail left coronary cusp leaflet and pressure half time of 132 ms. Invasive coronary angiography revealed a patent LCx stent and non-obstructive CAD. Decision-making Our patient's presentation in shock was initially concerning for toxicity associated with the accidental use of both a BB and nondihydropyridine CCB. Further workup revealed that the patient's underlying prosthetic AV failure with severe AI predisposed him to this decompensation. A heart team deemed him high-risk for SAVR, therefore, our patient underwent valve-in-valve TAVR. Conclusion Overdose of BB and nondihydropyridine CCB represents a fatal adverse event involving commonly prescribed medications. Patients with cardiac dysfunction, such as our patient with severe AI, are at increased risk of intolerance of these medications. In our patient with severe symptomatic AI of a prosthetic valve, definitive treatment is aortic valve replacement.
Volume
83
Issue
13
First Page
2996
