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Severe Mitral Regurgitation with Decompensated Heart Failure Due to Preeclampsia
Abstract Number: F-54
Abstract Type: Case Report/Case Series
Though mitral regurgitation (MR) is often well tolerated by the parturient, because of the decreased afterload and mild tachycardia of pregnancy, this is not always the case. We discuss a parturient with severe MR who had tolerated two previous term deliveries but presented with decompensated heart failure in the setting of increased afterload due to preeclampsia.
A 39-year-old G4P2 Honduran female with two previously uncomplicated term deliveries presented at 39 weeks gestation with two weeks of increasing dyspnea, an oxygen requirement, and pulmonary edema on chest x-ray. Echocardiogram demonstrated severe MR consistent with pre-existing rheumatic heart disease and a dilated left atrium. She was also diagnosed with preeclampsia. She was admitted to a cardiac unit for diuresis and fetal monitoring. She failed to improve and, overnight, a Caesarean section was performed under neuraxial anesthesia with arterial and central lines. During autotransfusion, central venous pressures rose, systemic pressures fell and she endorsed worsening dyspnea. She was stabilized with further diuresis, CPAP and norepinephrine and admitted to an ICU for post-operative monitoring. The remainder of her hospital course was uncomplicated, and she underwent uneventful mitral valve replacement 5 months post-partum.
Management goals for the parturient with severe MR include decreasing afterload to maintain forward flow, maintaining moderate tachycardia to decrease time for backflow, avoiding myocardial depressants, and maintaining sinus rhythm (1,2,3,4). Neuraxial techniques decrease afterload and support forward flow (1,2,3,5). “Autotransfusion” from placental contraction may cause decompensation due to acute fluid overload. It may also lead to increase atrial stretch and arrhythmia, which should be treated with immediate cardioversion. This may be managed with preemptive diuresis and respiratory support (e.g., CPAP) (6).
This patient presented with a chronic lesion, as evidenced by the atrial dilation and echocardiographic features consistent with rheumatic heart disease. However, her dyspnea, pulmonary edema, and previously uncomplicated deliveries suggested an acute process. We hypothesize that increased afterload and increased pulmonary capillary permeability due to preeclampsia (which was not present in previous pregnancies) was the precipitant factor for her decompensated heart failure during this pregnancy. Preeclampsia has not previously been described as a precipitant cause of decompensated heart failure in the parturient with severe MR.
1. Kaplan JL. Kaplan's Cardiac Anestthesia. 6th ed. St. Louis, MO: Saunders Elsevier, 2011.
2. Hines RA & Marschall KE. Stoelting's Anesthesia and Co-Existing Disease. 6th ed. Philadelphia, PA: Saunders Elsevier, 2012.
3. Chohan U, Afshan G, Mone A. Anaesthesia for Caesarean Section in Patients with Cardiac Disease. J Pak Med Assoc 2006; 56 (1): 32-38.
4. Graham TP, Duma