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Paradoxical Embolus and Stroke Following Balloon Valvuloplasty for Severe Mitral Stenosis During Pregnancy
Abstract Number: S2C-3
Abstract Type: Case Report/Case Series
Percutaneous balloon valvuloplasty (PBV) is the treatment of choice for severe mitral stenosis (MS) with heart failure during pregnancy. The procedure has high success rates (>94%), but with known potential serious complications. We present a case of severe MS treated with PBV at 26 weeks gestational age (GA) and complicated by stroke due to paradoxical embolus.
A 32yr, G2P1 at 22+3 weeks GA presented to an outside institution with severe shortness of breath, tachycardia, cough and weight gain. Childhood history of Sydenham’s Chorea and presence of a murmur on exam raised suspicion for undiagnosed rheumatic heart disease. TTE revealed severe MS with right heart failure and severe pulmonary hypertension. She was treated with furosemide and beta blockers over 12 days, with improvement in her MV gradient from 34 to 25 mmHg and RVSP from 150 to 70 mmHg, however she continued with NYHA Class IV heart failure symptoms of severe dyspnea.
She was transferred to our institution at 24+0 weeks GA for PBV consideration. As she was medically stable and desired full fetal intervention, PBV was deferred until 26+0 weeks. She decompensated 2 days prior to her procedure with severe orthopnea and pulmonary edema unresponsive to high dose diuretics. High flow nasal cannula with inhaled epoprostenol led to a notable improvement and allowed her to lie supine for the procedure. With a combination of local anesthetic topicalization and sedation she tolerated TEE to rule out left atrial thrombus. She underwent a successful PBV via right groin venous access and deliberate intra-atrial septum perforation. Post PVB she had immediate symptomatic improvement, MV gradient decreased (25 to 11 mmHg) and PA pressures improved (79 to 65 mmHg). Continuous fetal monitoring during PBV was Category 1 except during the two brief periods of balloon inflation. On POD 4 she experienced sudden onset left hemi-sensory deficits. Brain MRI revealed small acute embolic infarcts in right temporal and occipital lobes. Doppler showed a nearly occlusive thrombus in the right greater saphenous and common femoral vein. In conjunction with persistent atrial septal defect on TTE, this suggested paradoxical embolus leading to ischemic stroke. Therapeutic anticoagulation lead to complete resolution of neurological deficits. Serial TTEs showed sustained improvement in cardiac indices. She underwent uncomplicated repeat cesarean delivery with bilateral tubal ligation at 37 weeks GA.
PBV during pregnancy is generally reserved for severe MS with heart failure despite medical therapy. Patients with heart failure and severe orthopnea may not tolerate supine positioning for PBV; high flow nasal cannula with epoprostenol allowed this patient to avoid general anesthesia. This case also highlights a very rare complication of paradoxical embolus and emphasizes the need for thromboprophylaxis in these patients.
1. Indian Heart J 2016;68(6):780-2