Valvular heart surgery during pregnancy

Outcomes following balloon mitral valvuloplasty in pregnant females with mitral stenosis and significant sub valve disease with severe decompensated heart failure

BACKGROUND

Mitral stenosis may present with decompensated heart failure during pregnancy. Many patients do have advanced sub valve disease and present late with decompensated state. The outcomes of balloon mitral valvuloplasty (BMV) in such advanced sub valve disease with severe heart failure in pregnancy has not been specifically studied till now.

METHODS

A descriptive study looking at the immediate and long-term outcomes of pregnant patients with MS who presented with severe heart failure and sub valve disease who had undergone BMV.

RESULTS

Ninety-six patients were studied. The mean gestational age was 23.4 ± 10.9 weeks .Mean SpO2 was 89% at admission,17% were in cardiogenic shock and 33.33 were on mechanical ventilation. The mean Wilkin's score was 9.71 ± 2.1 and sub valve score was 3.3 ± 0.12. BMV was successful in 77 (80.2%) patients and failed in 19. In 5.2% cases, acute severe MR occurred. There were 11 maternal deaths (six in failed and five in success group). A successful obstetric outcome was seen in 71 patients in success (92%) and 11/19 (57%) in failed (P < 0.001). The obstetric outcomes were better in success versus failure group. Anova post hoc analysis showed sustained gradient reductions at 1 and 5 year follow-up (P = 0.03) in success group.

CONCLUSIONS

BMV offers substantial improvement in clinical outcomes among pregnant patients with MS and heart failure even with severe sub valve disease. The morality rate among failed was high at 31%. The obstetric outcomes were poor after a failed BMV. Outcomes following balloon mitral valvuloplasty in pregnant females with mitral stenosis and significant sub valve disease with severe decompensated heart failure.

Immediate Outcome of Balloon Mitral Valvuloplasty with JOMIVA Balloon during Pregnancy

INTRODUCTION

Rheumatic mitral stenosis is the most common Valvular Heart Disease encountered during pregnancy. Balloon Mitral Valvuloplasty (BMV) is one of the treatment option available if the symptoms are refractory to the medical management and the valve anatomy is suitable for balloon dilatation. BMV with Inoue balloon is the most common technique being followed worldwide. Over the wire BMV is a modified technique using Joseph Mitral Valvuloplasty (JOMIVA) balloon catheter which is being followed in certain centres.

AIM

To assess the immediate post procedure outcome of over the wire BMV with JOMIVA balloon.

MATERIALS AND METHODS

Clinical and echocardiographic parameters of pregnant women with significant mitral stenosis who underwent elective BMV with JOMIVA balloon in our institute from 2005 to 2015 were analysed retrospectively. Severity of breathlessness (New York Heart Association Functional Class), and duration of pregnancy was included in the analysis. Pre procedural echocardiographic parameters which included severity of mitral stenosis and Wilkin's scoring were analysed. Clinical, haemodynamic and echocardiographic outcomes immediately after the procedure were analysed.

RESULTS

Among the patients who underwent BMV in our Institute 38 were pregnant women. Twenty four patients (63%) were in New York Heart Association (NYHA) Class III. All of them were in sinus rhythm except two (5%) who had atrial fibrillation. Thirty four patients (89.5%) were in second trimester of pregnancy at the time of presentation and four (10.5%) were in third trimester. Echocardiographic analysis of the mitral valve showed that the mean Wilkin's score was 7.3. Mean mitral valve area pre procedure was 0.8 cm². Mean gradient across the valve was 18 mmHg. Ten patients (26.5%) had mild mitral regurgitation and none had more than mild mitral regurgitation. Thirty six patients had pulmonary hypertension as assessed by tricuspid regurgitation jet velocity. All of them underwent BMV with JOMIVA balloon. Post procedure mean mitral valve area was 1.7 cm² as assessed by echocardiography. Post procedure mean gradient across the mitral valve as assessed by echocardiography was 5 mmHg. Two patients had moderate to severe mitral regurgitation after the procedure and the rest had either no mitral regurgitation or mild mitral regurgitation after the procedure. None of the patients warranted mitral valve replacement after BMV. No patients had any manifestations of systemic embolism like cerebrovascular accident or limb ischemia after the procedure. None of the patients had preterm delivery or adverse fetal outcome during index hospitalisation.

CONCLUSION

Over the wire BMV is safe and effective method during pregnancy. The results are comparable to that of Inoue technique. BMV offers a good symptomatic improvement in pregnant women presenting with symptoms of pulmonary congestion because of Rheumatic mitral stenosis.

Successful fibrinolytic treatment in a pregnant woman with acute mitral prosthetic valve thrombosis

Pregnant patients with mechanical prosthetic heart valves pose a great problem for medical management. The problem is even greater in a pregnant woman with mechanical valve thrombosis. This article describes a pregnant woman with prosthetic mitral valve thrombosis who had a successful fibrinolytic treatment.

Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients

BACKGROUND

Pregnancy can cause life-threatening complications in women with mitral stenosis. Frequently, there is an urgent need to increase the mitral valve area mechanically. In selected cases, percutaneous mitral balloon valvotomy (PMBV) has emerged as a safe and effective alternative to surgical commissurotomy.

HYPOTHESIS

The study evaluates the effects of PMBV by the Inoue technique in nine pregnant patients with severe symptomatic mitral stenosis.

METHODS

The patients were in New York Heart Association (NYHA) functional class II to IV and had echocardiographic scores of < or = 8. The mean gestational age was 24.8 +/- 6.1 weeks. The patient's pelvic and abdominal regions were covered with a lead apron to protect the fetus from radiation. A stepwise dilatation technique was used. Fluoroscopy time was kept to 10 to 15 min.

RESULTS

One patient developed severe mitral regurgitation requiring emergency valve replacement. The remaining eight patients showed marked immediate symptomatic and hemodynamic improvement. After dilatation, the transmitral pressure gradient decreased from 20.8 +/- 6.5 to 7.3 +/- 1.4 mmHg (p = 0.001) and the calculated mitral valve area increased from 0.9 +/- 0.1 to 1.8 +/- 0.4 (p < 0.001). All patients had uneventful term deliveries of normal babies. On follow-up they were in NYHA functional class I.

CONCLUSIONS

Percutaneous mitral balloon valvotomy is a safe and effective procedure for selected pregnant patients with severe mitral stenosis. The procedure is well tolerated by the fetus. Severe mitral regurgitation requiring immediate surgery may occur occasionally. The possible harmful effects to the fetus from its exposure to radiation during PMBV are unknown.

Pregnancy in women with valvular heart disease

Patients with valvular disease who desire pregnancy or are already pregnant require specialised care. Ideally, women undergo preconceptual counselling that addresses any procedures needed to decrease the risks of pregnancy, including valve replacement, if the patient has symptoms at baseline. Management during pregnancy includes replacing any contraindicated medications with safer alternatives, optimising loading conditions, careful monitoring and aggressive treatment of any exacerbating factors. Rarely, percutaneous or surgical intervention is required during pregnancy. Labour and delivery often require invasive haemodynamic monitoring and a multi-disciplinary team for optimal maternal and fetal outcomes.

Percutaneous balloon mitral commissurotomy during pregnancy

Percutaneous balloon mitral commissurotomy was performed in 16 pregnant women aged 23 +/- 3 years (range, 16-39 years) who had severe mitral stenosis at pregnancies of mean gestational age 25 +/- 6 weeks. Ten patients were in New York Heart Association functional class III, and six patients were in functional class IV at the time of the procedure. All patients were symptomatic despite maximal medical therapy. The procedure was performed with the Inoue balloon. The mitral valve area increased from 0.9 +/- 0.3 to 1.8 +/- 0.3 cm2 (p < 0.05). The mitral valve pressure gradient decreased from 23 +/- 7 to 6 +/- 3 mm Hg (p < 0.05). The left atrial pressure decreased from 28 +/- 8 to 10 +/- 4 mm Hg (p < 0.05). The pulmonary artery pressure decreased from 59 +/- 18 to 33 +/- 12 mm Hg (p < 0.05). Fourteen patients continued their pregnancies to mean gestational age 37 +/- 2 weeks; all infants were healthy. Two patients had premature deliveries more than 1 month after the procedure due to obstetrical reasons. The two newborns died at day 2 of respiratory distress. Eleven women had vaginal deliveries and five had cesarean sections. All clinically improved to New York Heart Association functional class I or II. Excessive blood loss from the femoral puncture site that required transfusion occurred in one patient. Mitral regurgitation increased one degree in four patients, from 0 to 1+. Patients were observed until delivery. None had restenosis. The degree of mitral regurgitation remained unchanged. Percutaneous balloon mitral commissurotomy can be performed safely during pregnancy. It will effectively improve hemodynamics and symptoms in pregnant patients who have severe mitral stenosis and persistent congestive heart failure symptoms despite conventional medical treatment. There are no immediate detrimental effects of radiation on the fetus. Risks are lower than previously reported when surgical commissurotomy was performed.

Valvular Heart Disease in the Pregnant Patient

Anticoagulation for the pregnant patient with valve disease is problematic: both the underlying thrombotic disorder and the pharmacologic agents available for its treatment pose significant risks to the mother and fetus. There are no randomized controlled trial data available to guide decision-making for this patient population. Clinical treatment algorithms usually are derived from patient registries or case series with the obvious limitations of retrospective review, selection bias, historical controls, and small patient numbers. Prospective trials clearly are needed, but clinical research in the pregnant patient presents a myriad of ethical and legal challenges. Warfarin and unfractionated heparin, the mainstays of anticoagulant therapy, fall quite short in any analysis of efficacy and safety. There is an increasing use of low molecular weight heparins (LMWHs) in clinical practice but without evidence-based validation. Anticoagulant management of the pregnant patient must begin with full disclosure of the hazards and limitations of all forms of available treatments, preferably prior to conception. Treatment should be predicated on an assessment of the relative risks of thrombosis and hemorrhage. Careful monitoring and dosage adjustment are required throughout gestation, labor, delivery, and the puerperium.

[Practice Guidelines of the Spanish Society of Cardiology for the management of cardiac disease in pregnancy]

Maternal adaptation to pregnancy includes reproductive hormone interaction plasma, volume changes with an increase in total body water, vascular alterations with a decrease in systemic resistance and modifications associated with hypercoagulability. These explain, in part, the appearance of signs and symptoms, even in a normal pregnant woman, that are difficult to distinguish from those occurring in heart disease and why some cardiac abnormalities are not well tolerated during pregnancy. Cardiovascular abnormalities are considered the first non-obstetric cause of morbidity and mortality during pregnancy. Rheumatic and congenital heart diseases are currently the most frequent cardiopathy found in women of childbearing age, followed by hypertension, coronary artery disease and arrhythmia. Although pregnancy is well tolerated by most women with heart disease, there are some cardiovascular abnormalities which place the mother and the infant at extremely high risk: patients with congestive heart failure and severe cardiac dysfunction, pulmonary hypertension, cyanotic congenital heart disease, Marfan's syndrome, severe obstructive lesions of the left side of the heart, patients with prosthetic cardiac valves and antecedents of peripartum cardiomyopathy should be encouraged to avoid pregnancy and the interruption of pregnancy may be advisable in cases with great risk of disability or death. The most severe cardiopathies significantly increase the risk of fetal loss and the presence of a congenital cardiac abnormality in either parent increases the risk of congenital cardiac disease in the fetus. Medical care must be initiated early, prior to conception and women with cardiopathy should be informed of the possible risks of pregnancy to both the mother and fetus.

Pregnancy with St. Jude Medical Mitral Valve Prosthesis

From 1986 to 1995, 513 young women of childbearing age (11 to 45 years) underwent mitral valve replacement with a bileaflet St. Jude Medical prosthesis. Twenty-one patients became pregnant within 3 years postoperatively. The mean age of these patients at the onset of pregnancy was 27 ± 8 years (range, 16 to 43 years). Follow-up was complete for all pregnant patients. Of 11 who continued to take warfarin during pregnancy, one had a premature delivery, 2 had spontaneous abortions, and 8 had therapeutic abortions. Five patients who ceased oral anticoagulant therapy had normal deliveries but 4 underwent reoperation for valve thrombosis postnatally, with concurrent left hemiplegia in one case. The other 5 patients adhered to an anticoagulation protocol for pregnancy; there were 3 normal deliveries, 1 premature birth, and 1 abortion. There is a high risk of thromboembolism in patients with mechanical heart valves whose anticoagulants are interrupted during pregnancy. We believe that careful supervision can reduce maternal morbidity and mortality.

The use of pulsatile perfusion during aortic valve replacement in pregnancy

Cardiac operations are occasionally required during pregnancy. Despite a low maternal mortality, fetal mortality remains high. Previous reports have suggested maintenance of high perfusion pressure and flow rate as protective measures to maintain fetal viability. Recent experimental data suggest pulsatile perfusion may help preserve placental hemodynamic function. The successful use of pulsatile bypass to replace the aortic valve in a 25-year-old female at 14 weeks gestation, with both maternal and fetal survival, is presented.

Effects of Pregnancy on Long-Term Follow-Up of Mitral Valve Bioprostheses

Between 1986 and 1990, 304 females between 11 and 45 (mean, 33.9 ± 6.9) years of age underwent isolated mitral valve replacement with a bioprosthesis. Thirty-nine of the 285 survivors experienced 48 pregnancies during the late follow-up period (group 1). Structural valve deterioration occurred in 25 (64.1%) of these patients and in 70 (28.4%) of the 246 patients (group 2) who did not become pregnant (p < 0.01). The mean time at which structural valve deterioration occurred was 7.01 ± 1.19 years postoperatively (range, 4.74 to 8.36 years) for group 1 patients and 6.76 ± 1.34 years (range, 2.33 to 10.17 years) for group 2 patients (p > 0.05). Freedom from structural valve deterioration at 10 years was 22.9% ± 8.11% for group 1 and 29.24% ± 6.09% for group 2 (p > 0.05). We concluded that pregnancy did not influence the long-term outcome after mitral valve replacement with a bioprosthesis.

Valvular heart disease in pregnancy. A contemporary perspective

Valvular heart disease may have a significant impact on the course and outcome of pregnancy with implications for fetal as well as maternal health. Optimally, serious symptomatic valvular heart disease should be detected and treated before pregnancy. Whether a pregnant woman is known to have valvular heart disease or is diagnosed during pregnancy, it is imperative that she is managed by an experienced multidisciplinary team. Although medical therapy may alleviate symptoms of heart failure in some patients, definitive intervention either with percutaneous balloon valvuloplasty or with surgical valve replacement may be necessary.

Choosing a prosthetic heart valve

Although most of the available prosthetic heart valves function remarkably well, the variety of available choices attests to the inability of any single one to fulfill the requirements of the ideal valve substitute. The mechanical prostheses include the caged-ball, tilting-disc, and bileaflet valves. Tissue valves available in the United States are the Carpentier-Edwards and Hancock porcine heterograft valves and the Carpentier-Edwards pericardial valve. Review of several large comparative studies on valve performance reveals that the overall results with tissue and mechanical valves are about equal at the end of 10 years. The characteristics of each type of valve substitute dictate the selection of one prosthesis in preference to others for a particular patient. Mechanical prostheses are recommended for patients without contraindications for anticoagulants. Tissue valves are reserved for patients over 65 years of age or for patients in whom anticoagulation is contraindicated. Multiple other patient-related factors need to be considered in selecting the appropriate valve, including the psychosocial situation and patient preference.