Open heart surgery during pregnancy

Anesthetic management for emergency cesarean section and aortic valve replacement in a parturient with severe bicuspid aortic valve stenosis and congestive heart failure

“…The recommendations for CPB in the gravid patient are based on the objective to sustain adequate foeto-maternal gas exchange in view of the increased cardiac output of 30-60% above nonpregnant values: 1) use of normothermic or mild hypothermic (32-34°C) perfusion when feasible; 2) maintaining pump flow rates >2.5 L/min/m 2 , and a mean arterial pressure above 70 mm Hg (70 to 90 mm Hg); 3) minimum hemodilution (hematocrit >29%; 4) high PaO 2 (200-400 mmHg); 5) use of membrane oxygenator; 6) use of alpha stat pH management; 7) using pulsatile flow; 8) beating heart surgery is particularly desirable in parturients whose foetuses are at risk of hypothermia, hemodilution, and hyperkalemia during CPB; 9) keeping minimum bypass and ischemia time; 10) monitoring fetal heart rate and recording uterine contractions. [3,11,15,[26][27][28][29] In conclusion, the present case report demonstrates that LSCS with concomitant AVR can be safely performed under opioid-based general anesthesia technique in pregnant patient with critical AS. But, severe respiratory depression in the new born must be anticipated with the use of fentanyl.…”

“…[2,3,14] However, if cardiac surgery is necessary in a pregnant patient, it should be undertaken as early as possible in the gestation; preferably in the second trimester after the completion of organogenesis. [11,15] Brazilian consensus on heart disease and pregnancy recommends the surgical treatment for severe bicuspid AS at any stage during gestation when the gradient across the valve is greater than 70 mm Hg. [16] Pregnant patient with mild to moderate AS or those with severe AS who are asymptomatic or have mild symptoms can be managed conservatively during pregnancy with bed rest, beta blockers, and oxygen.…”

Positive maternal and foetal outcomes after cardiopulmonary bypass surgery in a parturient with severe mitral valve disease

“…1,2,5,7 These include maternal and foetal death, 1,2,5,7 intrauterine growth restriction, low postnatal birthweight and congenital malformations. 6 Sustained uterine contractions reduce uterine blood flow (UBF), which results in foetoplacental insufficiency and subsequent foetal hypoxaemia. 2,5 Foetal bradycardia, an indicator of foetal asphyxia, 2 may occur during CPB surgery initiation and emergence therefrom, 1,2,5,7 and may potentially be caused by the following factors: reduced systemic vascular resistance, low UBF, haemodilution, hypothermia, particulate or air embolism, obstruction of venous drainage during inferior vena cava cannulation, activation of inflammatory processes or maternal narcotic administration.…”

“…2,5-7 High foetal mortality is attributed to the above factors, which can affect foetal oxygen delivery during CPB surgery. 2,[5][6][7] Survival of healthy infants is as high as 56% post-CPB surgery in parturient women with severe cardiac disease. 8,9 Intraoperative foetal monitoring can help to correct some of the potential hazards 10,11 that result in inadequate foetal oxygen delivery.…”

“…5,7 Untreated maternal heart disease also places the foetus at risk, 2 and if open heart surgery is required, it is best undertaken in the second trimester. 2,6,8 This case study describes positive maternal and foetal outcomes after CPB surgery in a parturient with severe mitral valve disease.…”