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Mitral Valve Dehiscence in a 34 week OB Patient with prior Aortic and Mitral Valve Replacement for Endocarditis
Abstract Number: F-64
Abstract Type: Case Report/Case Series
We present a patient with prior valve replacement for infective endocarditis, with mitral valve dehiscence in the setting of recurrent endocarditis and pregnancy.
A 28yo G1P0 with history of IVDU and endocarditis requiring bioprosthetic aortic and mitral valve replacement, presented at 34weeks, 2 days with hypotension, tachycardia, and hypoxia. She reported recent onset fatigability, SOB, fevers, and continued IV cocaine and heroine use. TTE showed mitral regurgitation with rocking and severe pulmonary hypertension. A TEE was performed and under sedation which revealed a significant mitral perivalvular leak without evidence of vegetation.(1) Initial blood cultures were positive and she was started on broad spectrum IV antibiotics, gentle diuresis, and was planned for delivery due to her pulmonary hypertension and ensuing mitral valve decompensation.
Primary cesarean section under general anesthesia was planned for hemodynamic stability and readiness for emergent cardiac surgery intervention if necessary. Pre-induction arterial, internal jugular, and large bore peripheral IV access was secured. She was induced with etomidate, remifentanil bolus, and succinylcholine; and maintained on remifentanil infusion and isoflurane after delivery. After induction she had supraventricular tachycardia which was treated with esmolol. Surgery was complicated by poor placental tone secondary to placenta accreta. IM methylergometrine and IV oxytocin were administered and EBL was 800mL. She was subsequently extubated and admitted to our Cardiac Care Step-down Unit. She was continued on IV antibiotics for treatment of alpha hemolytic streptococcal bacteremia. Her bioprosthetic valves will be replaced upon finishing her antibiotic course, blood culture clearance, and IVDU cessation.
Recurrent endocarditis, and possibly pregnancy, may accelerate bioprosthetic structural valve deterioration.(2) Our patient was at risk of bioprosthetic valve dehiscence and right heart failure secondary to pulmonary hypertension. The successful management of patients with major cardiac issues in pregnancy requires multidisciplinary planning. Our OB/GYN, Cardiology, and OB Anesthesia teams met on multiple occasions to create a plan to deliver this patient safely.
1. 3D TEE image of this patient’s mitral perivalvular leak.
2. Badduke BR, et al. Pregnancy and childbearing in a population with biological valvular prosthesis. J Thorac Cardiovasc Surg 1991;102(2):179-86.