Cardiopulmonary bypass in pregnancy

A Historic Case of Cardiac Surgery in Pregnancy

Background. Heart disease is the leading cause of nonobstetric mortality in pregnant women. Because of high risk, medical management represents the first line of treatment. However, when medical treatment fails, cardiac surgery becomes necessary. Case Presentation. A 27-year-old female who underwent successfully cardiac surgery three times within 3 years. At the first time, she had an aortic valve replacement at 25 weeks of gestation after an infectious endocarditis complicated with an ischemic stroke. At 39 weeks of gestation, she had delivered, vaginally, a healthy baby boy weighing 2800 g. In the second time, pregnant again at 30 weeks of gestation, she had a mitral valve replacement with an aortic prosthesis reinforcement after a paraprosthetic regurgitation and a mitral vegetation. A fetal death in utero had occurred; the extraction of the fetus by cesarean section with a tubal ligation was performed after stabilization of the mother. In the third time, she underwent successfully a mitral prosthesis replacement with Bentall's procedure after a mitral prosthesis disinsertion with an abscess of aortic annulus due to new episode of infectious endocarditis. Conclusion. Our patient has assembled almost all poor prognosis factors, which makes her a real historic case, probably never described in the literature.

Indications for Cardiopulmonary Bypass During Pregnancy and Impact on Fetal Outcomes

Background: Cardiac operations in pregnant patients are a challenge for physicians in multidisciplinary teams due to the complexity of the condition which affects both mother and baby. Management strategies vary on a case-by-case basis. Feto-neonatal and maternal outcomes after cardiopulmonary bypass (CPB) in pregnancy, especially long-term follow-up results, have not been sufficiently described. Methods: This review was based on a complete literature retrieval of articles published between 1991 and April 30, 2013. Results: Indications for CPB during pregnancy were cardiac surgery in 150 (96.8 %) patients, most of which consisted of valve replacements for mitral and/or aortic valve disorders, resuscitation due to amniotic fluid embolism, autotransfusion, and circulatory support during cesarean section to improve patient survival in 5 (3.2 %) patients. During CPB, fetuses showed either a brief heart rate drop with natural recovery after surgery or, in most cases, fetal heart rate remained normal throughout the whole course of CPB. Overall feto-neonatal mortality was 18.6 %. In comparison with pregnant patients whose baby survived, feto-neonatal death occurred after a significantly shorter gestational period at the time of onset of cardiac symptoms, cardiac surgery/resuscitation under CPB in the whole patient setting, or cardiac surgery/resuscitation with CPB prior to delivery. Conclusions: The most common surgical indications for CPB during pregnancy were cardiac surgery, followed by resuscitation for cardiopulmonary collapse. CPB was used most frequently in maternal cardiac surgery/resuscitation in the second trimester. Improved CPB conditions including high flow, high pressure and normothermia or mild hypothermia during pregnancy have benefited maternal and feto-neonatal outcomes. A shorter gestational period and the use of CPB during pregnancy were closely associated with feto-neonatal mortality. It is therefore important to attempt delivery ahead of surgery/CPB or to defer surgery till late pregnancy.