Reoperative aortic and mitral prosthetic valve replacement in the third trimester of pregnancy

Cardiac operations during pregnancy: review of factors influencing fetal outcome

Women with underlying rheumatic heart disease, even if well compensated, can easily be affected by acute heart failure caused by out-of-the-ordinary cardiorespiratory requirements during pregnancy. In such cases, medical therapy is not always sufficient to drive a heart, and open heart operation might be necessary. Many factors associated with cardiac operations requiring cardiopulmonary bypass, such as hypothermia, can adversely affect both the mother and the fetus, but the morbidity and mortality rates are higher for the fetus than the mother. Because fetal heart tones were lost during cardiopulmonary bypass and were reheard in the intensive care unit in our case presentation, we have presumed that the loss of fetal heart tones should not always indicate fetal death and have discussed harmful factors in relation with the fetal morbidity and mortality in light of the literature.

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996

The outcomes of cardiovascular operations during pregnancy, at delivery, and post partum were reviewed from published material in the period 1984-1996. Surgery during pregnancy resulted in fetal-neonatal morbidity and mortality of 9% and 30%, respectively, and in maternal morbidity and mortality of 24% and 6%, respectively. Duration of pregnancy at surgery and duration and temperature of cardiopulmonary bypass did not influence fetal-neonatal outcome. Maternal complications and mortality of surgery immediately after delivery were 29% and 12%, respectively, and for surgery performed with a postpartum interval the respective rates were 38% and 14%. Hospitalization after week 27 of gestation and extreme emergency contributed significantly to poor maternal outcome. Maternal deaths were reported in 9% of valvular procedures and in 22% of aortic or arterial dissection repairs and pulmonary embolectomies. Fetal-neonatal risks of maternal surgery during pregnancy are high and unpredictable. Maternal risks of cardiovascular procedures during pregnancy are moderate, significantly increase if an operation is performed at or after delivery, and, overall, should be considered as higher than those in nonpregnant cardiovascular surgical patients.

Cardiopulmonary bypass in pregnancy

The cardiopathic patient can sustain acute heart failure during pregnancy. In such cases, if open heart operation is necessary to save the patient's life, the fetus could be seriously compromised after exposure to cardiopulmonary bypass. From 1958 to 1992, 69 reports of cardiac operations during pregnancy with the aid of cardiopulmonary bypass have been published. Maternal mortality was 2.9%. Embryofetal mortality was 20.2%. Examining only the last 40 patients, maternal and embryofetal mortality were 0.0% and 12.5%, respectively. Embryofetal mortality was 24.0% when hypothermia was used, compared with 0.0% while operating in normothermia. Maternal mortality did not change. The use of hypothermia during cardiopulmonary bypass provoked uterine contractions in several patients. Hypothermia decreases O2 exchange through the placenta. Pump flow and mean arterial pressure during cardiopulmonary bypass seem to be the most important parameters that influence fetal oxygenation. We speculate that cardiac operation is not a contraindication to pregnancy prolongation.

Anesthesia, cardiopulmonary bypass, and the pregnant patient

For the perioperative management of pregnant patients with severe cardiac or aortic disease who require a cardiac surgical procedure and cardiopulmonary bypass, a close, cohesive, working relationship must exist among several medical and surgical specialties. For appropriate management, the well-being of both the mother and the fetus must be considered. The best interests of the mother and the fetus may not coincide, and optimal therapy for one may be inappropriate for the other. We present 10 cases of severe cardiac or aortic disease in pregnant women who required surgical intervention. Eight patients underwent cardiopulmonary bypass during pregnancy, and two patients had cesarean section performed immediately before cardiopulmonary bypass. We also discuss the pertinent pharmacologic aspects related to the perioperative period and the management of cardiopulmonary bypass for the pregnant patient.