Case Report: Severe Prosthetic Mitral Valve Stenosis and Immediate Post Partum Mitral Valve Replacement in the Parturient
Abstract Number: 200
Abstract Type: Case Report/Case Series
Pregnancy in women with structural cardiac disease is associated with significant morbidity and mortality due to the increased demands on the cardiovascular system during the gestational and peripartum periods. We present a case of a 23 year-old female parturient who had undergone mitral valve replacement with a 29 mm Baxter porcine prosthesis 7 years prior to conception for palliation of chronic mitral regurgitation following an episode of rheumatic fever at the age of 13. The patient had sought preconception consultation with her cardiologist approximately 18 months prior to the estimated date of conception, and at that time she was reportedly asymptomatic with respect to her cardiac history. Transthoracic echocardiogram demonstrated a well-functioning prosthetic mitral valve, mild mitral valve stenosis with a mean valvular gradient of 7 mmHg, trivial mitral regurgitation, and normal biventricular function. She was not taking medications at that time and denied a history of atrial fibrillation or thrombotic events. She was otherwise healthy and had no known comorbidities. Her clinical picture and echocardiogram remained essentially unchanged until the latter portion of the second trimester. At that time, the patient developed progressive dyspnea and exercise intolerance, and was hospitalized on multiple occasions with orthopnea and pulmonary edema. Serial evaluations demonstrated progressive bioprosthetic mitral stenosis and rapidly developing pulmonary venous and arterial hypertension. She was urgently admitted at 30 and 5/7 weeks gestation for hemodynamic monitoring, antenatal monitoring, fluid management and diuresis . Transthoracic echocardiogram at the time of this admission revealed severe right ventricular hypertension and mitral stenosis with a mean gradient of 30mmHg. Diuretics and beta blockers were continued and fetal heart monitoring and bed rest initiated with a goal of delivery at 34 weeks. Her symptoms were initially stable with slight improvement. However, with an acute increase in dyspnea and orthopnea refractory to pharmacologic therapy and the apparent imminent need for repeat mitral valve replacement, the patient was taken to the operating room for urgent Cesarean-section and bilateral tubal ligation at 32 5/7 weeks gestation.
After rapid sequence intubation, central venous access and invasive arterial monitoring were attained and a pulmonary arterial catheter was placed. The operative course was uncomplicated. The patient remained intubated post-operatively and was monitored in the cardiac surgical intensive care unit. Two days after Cesarean section she was taken to the operating room for repeat mitral valve replacement with a 29 mm St. Jude Medical mechanical valve without complications. She was extubated on the first post-operative day and recovered without incident. She was discharged home on post-operative day 9.