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JACC March 12, 2019

Volume 73, Issue 9

FIT Clinical Decision Making

SEVERE MITRAL STENOSIS AND PULMONARY HYPERTENSION IN PREGNANCY: WHEN TO ACT
Poster Contributions
Poster Hall, Hall F
Saturday, March 16, 2019, 3:45 p.m.-4:30 p.m.

Session Title: FIT Clinical Decision Making: Valvular Heart Disease 2

Abstract Category: Valvular Heart Disease
Presentation Number: 1162-141

Authors: Ikenna Erinne, Amit Alam, Michael Huang, Kanika Mody, Aziz Ghaly, Deepa Iyer, Robert Wood Johnson University Hospital, New
Brunswick, NJ, USA
Background: The management of patients with severe mitral stenosis (MS) during pregnancy is complicated and demands a
multidisciplinary approach for the best possible outcome
Case: A 34-year-old pregnant Filipino female with severe MS due to rheumatic heart disease presented at 29 weeks and 4 days of
pregnancy with NYHA class 4 symptoms and was referred to the advanced heart failure team for management. Echocardiogram revealed
normal Left ventricular ejection fraction, increased right ventricle (RV) cavity size with decreased RV systolic function, severe bi-atrial
enlargement, mitral valve (MV) area of 1.40cm2, moderate mitral regurgitation (MR) and moderate/severe tricuspid regurgitation with a RV
systolic pressure (RVSP) of 99 mmHg
Decision-making: MV balloon valvuloplasty was not an option due to MR. Medical therapy was initiated with intravenous diuresis and
beta blockers with a heart rate goal of 70-80 beats per minute. After one week the patient achieved significant symptomatic improvement
to NYHA class 2 but repeat echocardiogram was notable for severely increased RV size and RVSP of 100mmHg. The patient underwent
cesarean section in the cardiac operating room two days later at 31 weeks’ pregnancy. Due to the clinical tenuousity, access for
extracorporeal membrane oxygenation was obtained and cardiothoracic surgery was on standby for emergency valve replacement in
the event of deterioration during delivery. Following uncomplicated delivery, the patient was further medically optimized in the coronary
care unit with hemodynamic monitoring with pulmonary artery catheter and use of diuretics, inotropes and pulmonary vasodilators and
successfully underwent a mechanical MV replacement one week later
Conclusion: The aim of medical therapy was to prolong pregnancy to 32 weeks (and possibly 34 weeks) for maximal fetal viability, but
due to concern for maternal wellbeing, early delivery was pursued. This case highlights the importance of a multidisciplinary approach in
the management of severe MS in late-stage pregnancy to determine optimal timing and mode of delivery, especially when MV balloon
valvuloplasty is not feasible