1441 Current Women’s Health Reviews, 2016, 12, 141-143
CASE REPORT ISSN: 1573-4048 eISSN: 1875-6581
Volume 12, Number 2
Emergent Balloon Mitral Valvuloplasty During Pregnancy: A Case Report BENTHAM SCIENCE
Sedigheh Ayati1, Leila Pourali1,*, Mohsen Mouhebati2, Hourieh Soleimani3, Fatemeh Teimouri Sani3 and Elnaz Ayati4 1
Women's Health Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; 2Department of Cardiovascular, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; 3School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; 4Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
ARTICLE HISTORY Received: March 15, 2016 Revised: September 13, 2016 Accepted: October 17, 2016
Abstract: Introduction: Mitral stenosis (MS) is the most common type of valvular heart disease leading to maternal and neonatal complications. Balloon mitral valvuloplasty (BMV) is considered as a gold standard treatment for severe MS which does not respond to medical therapy. This study reports a case of emergent balloon mitral valvuloplasty during pregnancy.
R N est ot ric Fo te rD dC is on tri te bu n tio t n
Current Women's Health Reviews
Send Orders for Reprints to
[email protected]
DOI: 10.2174/15734048126661610211145 41
Case Report: A 35 year-old pregnant woman, G2L1 at 38th weeks of gestation was referred was referred because of dyspnea and orthopnea. Echocardiography revealed Severe MS, Mitral valve area of 0.9 cm and pulmonary artery pressure (PAP): 80 mmHg, ejection fraction (EF): 40%. Urgent BMV was planned. Delivery was carried out 4 hours after BMV without any maternal and neonatal complications. Conclusion: BMV is a safe and effective procedure for the treatment of severe mitral stenosis in pregnancy, even in emergent situation.
Keywords: Balloon valvuloplasty, mitral valve stenosis, pregnancy. INTRODUCTION
The incidence of valvular heart disease in pregnancy is about 0.5-1.5 % [1]. Mitral stenosis is the most common type of valvular heart disease which is associated with maternal and neonatal morbidity and mortality [2].
Rheumatic fever (RF) is the most common etiology of mitral stenosis (MS) and is still highly prevalent in developing countries [3]. Symptoms of MS might be accelerated during pregnancy due to several physiologic changes in cardiovascular system, which include a 50% increase in circulating blood volume, a significant rise of cardiac output and a decrease in systemic vascular resistance [4]. The increased blood volume and tachycardia, together, can lead to pulmonary edema, especially in the peripartum period [5]. Balloon mitral valvuloplasty (BMV) is considered gold standard treatment in patients with severe MS who do not respond to maximal medical therapy. This method is increasingly performed on patients with isolated MS [2]. There are limited published reports about accomplishment of BMV at emergent situation during pregnancy. This study *Address correspondence to this author at the Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Tel: +98-5138412477; Fax: +98-5138430569; E-mail:
[email protected]
1875-6581/16 $58.00+.00
reports the successful application of emergent BMV for a pregnant patient with severe mitral stenosis.
CASE REPORT
A 35-year-old pregnant woman, G2L1 (gravid 2, live 1) at 38 weeks of gestation, was referred to a local health care center with 2 months of dyspnea and orthopnea. She mentioned occasional palpitations over the last year, for which propranolol 10 mg once daily was prescribed. Meanwhile, she had not been visited by any obstetrician or cardiologist. Her first pregnancy, which was nine years ago, was uneventful. She was referred to the academic hospital, Mashhad University of Medical Sciences in 2015, which allowed care by an obstetrician and cardiologist. Her primary physical examination revealed the followings: pulse rate (PR): 130/min, respiratory rate (RR): 24/min, blood pressure (BP): 100/60 mmHg, crackles at the bases of the lungs and a diastolic murmur. Echocardiography revealed severe MS and pulmonary hypertension by demonstrating ejection fraction (EF) of 40%, mitral valve area (MVA) of 0.9 cm and pulmonary artery pressure (PAP) of 80 mmHg. Emergent BMV was planned for her in a tertiary center. Following local anesthesia, the septostomy was done using a right femoral artery approach under fluoroscopy guidance, and the BMV with Innou balloon number 26 was
© 2016 Bentham Science Publishers
142 Current Women’s Health Reviews, 2016, Vol. 12, No. 2
performed with a pressure of 22-26 mmHg. Left atrial pressure was dropped from 25 to 12 mmHg. No immediate complication was noted, and the patient was transferred to cardiac care unit (CCU). About 4 hours later, rupture of membranes occurred. She was observed in the CCU for another 3 hours. Then the angiographic port was exited and she was transferred to the delivery room. The second phase of delivery was shortened by using vacuum extraction. A healthy neonate with normal Apgar scores 9,10, and weight of 3200 g was delivered. The mother discharged from hospital 3 days after delivery without any cardiac symptoms or puerperal complication. In patient’s follow-up, there was no sign of restenosis in echocardiography. DISCUSSION
gestational age (38 weeks) and emergent clinical situation, the maternal and neonatal outcomes were optimal. A similar study evaluated BMV at non-emergent situation in 16 pregnant women with mean gestational age of 25±6 weeks suffering from severe MS. Other than two cases of premature delivery and fetal loss, no maternal mortality and no restenosis occurred. Therefore, they concluded this procedure can be performed safely during pregnancy compared to surgical commissurotomy [13]. In the present case, not only maternal and neonatal outcomes were optimal, but also maternal follow-up showed no valvular problems after delivery. Ben Farhat et al. evaluated the efficacy and safety of BMV in 44 pregnant women with MS. One patient required early valve replacement due to severe mitral regurgitation, but no other complications were observed. They proposed BMV as the treatment of choice for pregnant women with severe medical-resistant MS [5]. Others have also reported successful application of BMV during pregnancy
R N est ot ric Fo te rD dC is on tri te bu n tio t n
MS commonly affects pregnant women in developing countries where rheumatic heart disease is still prevalent [6]. As cardiac demand increases during the course of pregnancy, the morbidity and mortality of the underlying heart disease rises. Most patients respond well to adequate medical therapy; however in some patients, maximal medical treatment is not successful to relief the symptoms; thus an invasive intervention is required [7].
Ayati et al.
In severe symptomatic patient, mitral commissurotomy must be attempted by either open mitral commissurotomy (OMC), closed mitral commissurotomy (CMC) or ballooning [8]. According to Born et al., in patients with cardiac surgery during pregnancy, the fetal mortality rate was 33.3%, while maternal mortality rate reached 13.3% [9].
ince the introduction of percutaneous dilation of the S mitral valve using a balloon catheter in 1984, it has become an extremely effective therapeutic method. As a non-surgical and safe treatment of rheumatic mitral stenosis, BMV prevents surgical commissurotomy [2]. Percutaneous balloon mitral valvuloplasty during pregnancy is reported to be more effective and safe compared to mitral valve commissurotomy. In the study by De Souza et al., the success rate of BMV was 95%, and lower neonatal and fetal complications were found compared to surgical commissurotomy [10]. In current case also there was no fetal or neonatal complication after the procedure. Adequate perioperative multidisciplinary management between the anesthesiologist, cardiologist and obstetrician can decrease peripartum mortality and morbidity [11]. The efficacy and safety of percutaneous balloon mitral valvotomy (BMV) has been further investigated by the study of Gupta et al. They reported BMV as feasible, safe, and effective during pregnancy with excellent maternal and fetal outcomes [12]. Another study reported the outcomes of non-urgent BMV in 33 pregnant women with a mean gestational age of 21-22 weeks. The outcomes were excellent for both mothers and neonates, and there was no mortality related to the procedure as well. Severe mitral regurgitation was observed in only one case [2]. In this report, although the patient was in advanced
The current report exemplifies success when performing BVM during pregnancy. Even in advanced gestational age and in emergent situation, BMV can be performed during pregnancy with excellent outcomes. CONCLUSION
BMV is a safe and effective procedure for the treatment of severe MS in pregnancy, even during emergent situations. CONFLICT OF INTEREST The authors confirm that this article content has no conflict of interest. ACKNOWLEDGEMENTS Declared none.
REFERENCES [1]
[2]
[3] [4] [5] [6] [7] [8]
[9]
Glantz JC, Pomerantz RM, Cunningham MJ, Woods JR Jr. Percutaneous balloon valvuloplasty for severe mitral stenosis during pregnancy: a review of therapeutic options. Obstet Gynecol Surv 1993; 48(7): 503-8. Abdi S, Salehi N, Ghodsi B, et al. Immediate Results of percutaneous Trans-Luminal Mitral commissurotomy in pregnant Women with severe Mitral stenosis. Clin Med Insights Cardiol 2012; 6: 35-9. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever– Authors' reply. Lancet 2005; 366(9494): 1355-6. Scirica BM, O'Gara PT. Valvular heart disease in pregnancy. Curr Cardiol Rep 2006; 8(2): 83-9. Ben Farhat M, Gamra H, Betbout F, et al. Percutaneous balloon mitral commissurotomy during pregnancy. Heart 1997; 77(6): 564-7. Marijon E. Rheumatic heart disease. Lancet 2012; 379(9819): 953-64. Madazli R, Sal V, Cift T, Guralp O, Goymen A. Pregnancy outcomes in women with heart disease. Arch Gynecol Obstet 2010; 281(1): 29-34. Ahmed W, Aziz S, Rehman F, et al. Percutaneous Transvenóus. Mitral Commissurotomy In A Pregnant Adolescent At AFIC/ NJHD. Pak Heart J 1998; 31(3-4): 59-61. Born D Massonetto JC, de Almeida PA, Moron AF, et al. Heart surgery with extracorporeal circulation in pregnant women. Analysis of materno-fetal outcome. Arq Bras Cardiol 1995; 64(3): 207-11.
Emergent Balloon Mitral Valvuloplasty During Pregnancy: A Case Report
[11]
de Souza JA, Martinez EE Jr, Ambrose JA, et al. Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy. J Am Coll Cardiol 2001; 37(3): 900-3. Benali Zel A, Ahmaidi H, Rachidi K, Omari D. Mitral stenosis with term pregnancy: how to manage this case? Pan Afr Med J 2013; 14: 144.
[12]
[13]
143
Gupta A, Lokhandwala YY, Satoskar PR, Salvi VS. Balloon mitral valvotomy in pregnancy: maternal and fetal outcomes. J Am Coll Surg 1998; 187(4): 409-15. Abouzied AM, Al Abbady M, Al Gendy MF, et al. Percutaneous balloon mitral commissurotomy during pregnancy. Angiology 2001; 52(3): 205-9.
R N est ot ric Fo te rD dC is on tri te bu n tio t n
[10]
Current Women’s Health Reviews, 2016, Vol. 12, No. 2
