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Decompensated heart failure in a parturient with multivalvular rheumatic heart disease
Abstract Number: RF7B10-415
Abstract Type: Case Report Case Series
Pregnancy can present challenges for women who have had previous repair of prosthetic heart valves as valve dysfunction may lead to the development or exacerbation of heart failure. Prosthetic valve dysfunction may include valve stenosis, regurgitation or both. Bioprosthetic valves have a significantly higher risk of failure than mechanical valves, which can pose challenges for women of child bearing age with a history of valve replacement.
Our patient is a 37 year old Vietnamese female with a history of rheumatic aortic, mitral, and tricuspid valve disease who underwent AVR/TVR/MVR with bioprosthetic valves in 2003. She had been doing well for years and underwent IVF in 2018. Her pregnancy was uncomplicated until the 3rd trimester when she presented to a cardiologist with symptoms of acute heart failure. A TTE revealed aortic, mitral, and tricuspid valve stenosis. She was referred to MFM and was well compensated on her initial visit. However, during a cardiology follow-up she was noted to be in atrial fibrillation with rapid ventricular response and in decompensated bi-ventricular heart failure with an EF of 30%. She was admitted to the L&D high risk service where an arterial and central line was placed by the OB Anesthesia team. She was subsequently started on esmolol, furosemide, digoxin, and heparin. After diuresing 13 liters she spontaneously reverted back to sinus rhythm. A repeat TTE revealed normalized LV/RV function with an EF of 55%. She then underwent elective CS-BTL at 32 weeks with a slow dose labor epidural in the cardiac OR with cardiac anesthesia. Cardiothoracic surgery was also present in case of an emergency necessitating immediate placement on ECMO. Her intraoperative and postoperative course was uncomplicated and she was discharged with plans for elective valve surgery once she had fully recovered from pregnancy.
Repeat valve replacement during pregnancy should be delayed given the fetal risks. Although experience during pregnancy is limited, a valve-in-valve intervention is a potential alternative to valve surgery . Women with high-risk valvular lesions should have prenatal care as well as delivery at a center with the resources available to care for both the patient and the infant . A labor and delivery plan should be prepared in advance with a multidisciplinary care team. These patients should have continuous telemetry, and if possible, intra-arterial monitoring during the labor and delivery period. They may also require this continued monitoring post-partum in an ICU setting. It is suggested that a vaginal delivery with appropriate analgesia and minimization of Valsalva in these women is ideal.
 Double Trouble: A Case of Valvular Disease in Pregnancy. Circulation. 2016;133(22):2206.
 Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147.