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Cesarean delivery of an anticoagulated parturient with high pressure gradients across bi-leaflet St. Jude mitral and tricuspid mechanical valves: a case report
Abstract Number: T-41
Abstract Type: Case Report/Case Series
We present a 24-year-old parturient, G6P1131, with St. Jude mechanical valves at the tricuspid and mitral positions, who was admitted for preterm labor at 32 weeks gestation. A cesarean delivery was performed while the patient was anticoagulated.
She had a history of rheumatic fever, which prompted her first mitral valve balloon valvotomy; however she required two additional mitral valve replacements for stenosis and a tricuspid valve replacement for severe tricuspid regurgitation. At admission she had elevated mitral and tricuspid valve pressure gradients (mean gradients of 9.5mmHg and 8.1mmHg, respectively) with preserved systolic function and clinically meeting New York Heart Association (NYHA) Class III criteria. In addition, she had experienced one cerebral vascular accident (CVA) and two pulmonary emboli (PE) while on anticoagulation. When admitted, her INR was 4.8, which was reversed with fresh frozen plasma and vitamin K. Unfractionated heparin infusion was started with a goal PTT of 75-95. The patient developed dyspnea with high suspicion of a PE, so her heparin infusion was titrated to a goal PTT of 90-110. Given the patient’s propensity for thrombus formation and the inability to effectively reverse the fetal anticoagulation (the parturient was anticoagulated on Coumadin prior to admission), the decision was made to perform a cesarean delivery with continuation of her heparin infusion with a goal PTT of 50-60 during surgery. Our cardiothoracic surgeons were on standby for emergency cardiac bypass and valve replacement.
The patient underwent a successful cesarean delivery under general anesthesia with less than one liter of blood loss and delivered a healthy infant (Apgars 1, 8). Intraoperative transesophageal echocardiography (TEE) was performed after the induction of general anesthesia and found near normal gradients across the mitral and tricuspid valves. The mitral valve appeared to be functioning well. A detailed 3D TEE examination showed that one of the leaflets of the tricuspid valve was immobilized, likely due to residual thrombus. Because the flow across the tricuspid valve was not obstructed there was no indication for valve replacement during the surgery. The patient was extubated after completion of the cesarean delivery and transported to the intensive care unit in stable condition.
The heparin infusion was increased to a goal PTT of 90-110 six hours after the cesarean delivery. She developed a subsequent hematoma anterior to the uterus requiring transfusion and expectant management. She was discharged 3 weeks after her cesarean delivery meeting NYHA Class II criteria, a goal INR of 3.5 and a transthoracic echocardiogram showing mean gradients across the mitral and tricuspid valves of 6mmHg and 4mmHg, respectively. To our knowledge, this is the first case report of a parturient who underwent a successful cesarean delivery while fully anticoagulated on a continuous heparin infusion.