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Management of Newly Diagnosed Severe Mitral Stenosis in Pregnancy
Abstract Number: SU-58
Abstract Type: Case Report/Case Series
Cardiovascular disease is a leading cause of pregnancy-related mortality in the United States, and is increasing as a proportion of total maternal deaths. Mitral valve stenosis (MS) is the most common acquired valvular abnormality encountered in pregnant women, and is often first diagnosed in pregnancy due to worsening symptoms.
A 32 y/o G5P3 at 23 wks gestation who recently moved from Pakistan presented with palpitations. Examination and EKG revealed supraventricular tachycardia at 214 bpm. Blood pressure was 110/70 and after failed vagal maneuvers she spontaneously converted to sinus tachycardia at 109 bpm. Echocardiography showed severe MS (mean gradient 34 mmHg) with trivial regurgitation, severe pulmonary hypertension, RV systolic pressure (RVSP) 95 mmHg, severe RV enlargement, severe tricuspid regurgitation, normal LV function, severe bi-atrial enlargement, and no evidence of left atrial thrombus. Immediate treatment focused on heart rate reduction with metoprolol as she was otherwise stable without symptoms of dyspnea or volume overload.
The next day she underwent percutaneous mitral balloon valvuloplasty (PBMV) under MAC. Repeat echocardiogram showed reduction of mitral valve (MV) gradient to 8 mmHg, RVSP of 51 mmHg, and reduction in tricuspid regurgitation. She continued on metoprolol 50 mg b.i.d and subQ heparin 7500 units b.i.d., had no further episodes of SVT, was asymptomatic, and delivered a healthy boy vaginally at 36 wks with epidural analgesia.
Overall maternal morbidity relates both to the severity of MS and degree of prepregnancy symptoms. The physiologic burden presented by pregnancy worsens symptoms. As cardiac output increases, the gradient across the MV increases. Untreated, this creates pulmonary hypertension, RV failure, and pulmonary edema. Heart failure occurs frequently in parturients with moderate-severe MS, even in previously asymptomatic women. It usually presents in the second and third trimesters, and is often progressive. Atrial arrhythmias are common and increase the risk for heart failure and thromboembolic events. Medical treatment centers on heart rate reduction with beta blockers, physical rest, and anticoagulation. Despite correction of her MS, our patient remained on anticoagulation because of left atrial enlargement, pulmonary hypertension, and concern for paroxysmal atrial tachyarrhythmias. Diuretics may be used for symptomatic management of volume overload, but were not needed in this case described above.
For women with severe or progressive disease, PBMV improves maternal outcomes. This is ideally performed after 20 weeks gestation in patients with severe and/or refractory symptoms despite optimal medical treatment. MV surgery carries increased fetal and maternal risk and is reserved for those who are not suitable candidates for PBMV or when the mother’s life is in danger without an immediate corrective procedure.
1. Anesthesiology 2011;114:949-57
2. Eur Heart J 2011;32:3147-97