Double Trouble

Abstract

ForewordInformation about a real patient is presented in stages (boldface type) to expert clinicians (Drs Ganame, Whitlock, Velianou, and Natarajan), who respond to the information, sharing their reasoning with the reader (regular type). A discussion by the authors follows. P atient presentation: A 29-year-old woman born in Canada, gravida 3, para 2 at 12 weeks gestation, presented to the cardiac pregnancy clinic with a 1-month history of progressive shortness of breath on exertion and chest discomfort. Her medical history was significant for stenosis of a congenital bicuspid aortic valve for which she underwent surgical aortic valve replacement with a #23 Carpentier-Edwards Perimount Magna ease porcine bioprosthetic valve 5 years earlier at the age of 24. There was a questionable history of rheumatic fever at the age of 21; investigations revealed positive antistreptolysin and Sjögren-specific antibody A titers. She was treated with valproic acid for an irregular tremor thought to be Syndenham chorea. The pathology from her surgery did not reveal any evidence of rheumatic disease.She went on to have 2 successful pregnancies at the age of 26 and 27 years without complications. Her last formal review was 1 year before, during her second pregnancy at 34 weeks gestation. Echocardiography showed mild prosthetic valve aortic stenosis with a peak/mean gradient of 41/27 mm Hg, normal ejection fraction, with increased gradients across the prosthetic valve thought to be secondary to a high-output state. She became pregnant unexpectedly 9 months after her second pregnancy and now had progressive shortness of breath and typical angina on exertion; she was unable to climb 1 flight of stairs or push her baby's stroller without having to stop for prolonged periods. Her medications included aspirin, monthly intramuscular penicillin, and maternal vitamins. On physical examination, her blood pressure was 105/66 mm Hg, heart rate 101 beats/min regular, and normal respiratory rate; oxygen saturation was 98% on room air. She was comfortable and in no acute distress. Jugular venous pressure was 5 cm above the sternal angle with a negative abdominojugular reflex. Carotid pulse was of normal volume and contour, with no audible bruits. There was a midline sternotomy scar and the apical impulse was sustained. Auscultation revealed a normal S1, grade 2 late-peaking systolic ejection murmur best heard at the base with radiation to the carotid base, soft S2, and no S3 or S4. Lungs were clear to auscultation bilaterally. There was no pedal edema, all peripheral pulses were palpable, and the abdomen was soft, nontender. A 12-lead ECG revealed sinus tachycardia, with normal axis, normal intervals, and borderline left ventricular hypertrophy by voltage criteria (Figure 1).Dr Ganame: Dyspnea in pregnancy is a common presentation encountered by family physicians, emergency physicians, general internists, obstetricians, respirologists, and cardiologists. A thorough review should be performed to assess whether the symptoms are part of the normal ...

Perioperative management of transcatheter, aortic and mitral, double valve-in-valve implantation during pregnancy through left ventricular apical approach

“…[ 8 ] There were case reports of transcatheter aortic valve implantation during pregnancy, but all were done through the femoral route. [ 9 10 ] Transfemoral, transatrial septal, and antegrade mitral valve implantation has been successfully tested in human trials using the CardiAQ transcatheter mitral valve (Edwards Lifesciences, Irvine, CA, USA), but it was not commercially available. [ 11 ] Decision to deploy both Edwards Sapien XT valves through the LV apical approach was taken because this valve can be deployed in mitral position only through this approach and this is a standardized alternative route for its deployment in the aortic position.…”

“…[ 12 ] Strategies to minimize radiation exposure are avoidance of unnecessary radiological investigations, use of appropriate radiation shields, avoid/restrict cineradiography, and minimize the total duration and amount of radiation by depending more on fluorography and fluoro-grab at a lower frame rate and “LOW” power setting. [ 10 ] A computed tomographic (CT) angiogram could be avoided in this patient because the in situ prosthetic valve sizes were known and the planned approach was through the LV apex. A transfemoral approach requires a CT angiographic scan to assess the size and nature of femoral arteries, iliac arteries, and aorta and mandates fluoroscopic guidance while advancing guidewires, catheters, and valve assembly through these vessels during the procedure.…”

Subacute Infective Endocarditis of Aortic Valve During Pregnancy

“…Our patient had infective endocarditis secondary to the fibrosed aortic valve, which is very rare but lethal to both the mother and fetus [ 11 ]. The patient, in this case, had the emergent cesarean section followed by successful replacement of aortic valve which helped reduce the risk of mortality in both the mother and the fetus.…”

TAVR Beyond Fetal Viability

“…Previously published literature on AVR during pregnancy was all in the pre-viable period, due to the inability to deliver even a pre-viable fetus in conjunction with the inability to further delay cardiac surgery based on maternal status ( Table 1 ). 5 , 6 , 7 , 8 , 9 However, preterm delivery even after viability may still carry significant neonatal morbidity and mortality and, if able to be avoided, is strongly preferred. Orwat et al 3 found that the peak aortic gradient before pregnancy as a continuous variable was the only independent predictor of complications.…”