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Not Your Typical Dyspnea of Pregnancy: Transcatheter Valve-in-Valve Replacement During Pregnancy
Abstract Number: F1C-3
Abstract Type: Case Report/Case Series
Severe aortic stenosis (AS) in pregnancy can cause maternal, and thus fetal, decompensation due to the inability of the stenotic valve lesion to handle the demand of the increased heart rate and stroke volume (1,2). Severe AS is an indication for cardiac surgery in pregnancy, and transcatheter aortic valve-in-valve implantation (VinV) is an option for redo AS correction (1-3). This procedure in pregnant patients demands a multidisciplinary approach with interventional cardiology, maternal fetal medicine (MFM), anesthesiology, and radiology. We report a case of a pregnant patient with severe AS who presented for VinV.
A 30-year-old woman G2P1 at 19 weeks gestation presents for VinV with increasing dyspnea for 3 months. Her medical history includes ESRD s/p kidney transplant, severe AS s/p surgical aortic valve replacement with a bioprosthetic valve, hyperparathyroidism s/p parathyroidectomy, and hypertension. Due to her extensive medical history and concurrent pregnancy, the patient was deemed a high risk for a redo surgical aortic valve, and a consensus to proceed with VinV under general anesthesia was made. Her preoperative transthoracic echo (TTE) demonstrated a normal EF, a well-seated bioprosthetic valve with severe stenosis, a peak transaortic velocity of 6.2 m/s, mean transaortic gradient of 92 mmHg, a calculated area of 0.8 cm2, and RVSP of 52 mmHg. Patient received aspiration prophylaxis, and general anesthesia was induced with a rapid sequence. An arterial line was placed for hemodynamic monitoring, and diligent care was used to avoid hypotension. Transesophageal echo (TEE) confirmed the preoperative TTE findings. The interventional cardiologist provided central access with their left femoral venous sheath. Under rapid ventricular pacing, the bioprosthetic valve was deployed without complication. Heart rate was otherwise maintained in normal sinus rhythm from 60-90 bpm. The post-procedure TEE showed unchanged systolic function, the VinV aortic bioprosthesis well-seated, a peak velocity of 3.6 m/s, a mean gradient of 27 mmHg, and no paravalvular regurgitation. The patient was extubated uneventfully and transported to the intensive care unit. The post-operative exam by MFM confirmed fetal heart tones within normal limits. At 24 hours post-operative, the patient reported improvement with her shortness of breath and denied any complications. Four months later, she had a successful, uncomplicated spontaneous vaginal delivery.
Coordinated planning is critical in any nonobstetric procedure in pregnant patients for the well-being of the mother and the fetus. Combining cardiovascular and obstetric anesthetic considerations provided a safe, comprehensive plan leading to a successful outcome for our pregnant patient’s transcatheter valve replacement.
1. Circulation. 2016; 133: 2206-2211 2. Circ Cardiovasc Interv. 2016; 9:e004006 3. Clin Obstet Gynecol. 2009; 52(4); 535-545