Pregnancy-Related Cardiovascular Complications: Case Presentation and Review of Literature
AbstractBackground: Cardiovascular complications that can cause severe catastrophic outcomes for both the mother and the fetus are rarely seen during pregnancy. Time to diagnosis is often delayed by a low degree of suspicion and atypical presentation. We report surgical strategies in three pregnant women with cardiovascular complications.
Methods: A retrospective search from 2009 to 2016 identified three pregnant women who underwent urgent cardiac surgery. We used extracorporeal circulation (ECC) without cesarean section with careful follow-up of the fetuses during the perioperative and postoperative period. We used levosimendan as a potent inodilator in all patients to increase feto-placental blood flow and fetal heart rhythm.
Results: Median time to diagnosis was 23.8 h (range 11.7-120 h) and median time from diagnosis to arrival in the operating theater was 9.8 h (range 7.4-19.8 h). One patient with prosthetic heart valve thrombosis underwent concomitant cesarean section prior to cardiac surgery. In a young pregnant woman who had spontaneous dissection of the left anterior descending artery, on-pump beating heart coronary artery bypass grafting was performed without cross clamping. Two and three months after surgery, cesarean sections were performed without any complication in two pregnant women.
Conclusion: Because unusual cardiovascular complications are the main cause of maternal and/or fetus death during pregnancy, prompt and exact diagnosis is very important. Life-saving surgical strategy with the help of appropriate teams are necessary to optimize outcome for both
mother and baby.
Abildgaard U, Sanset PM, Hammerstrom J, Gjestvang FT, Tveit A. 2009. Management of pregnant women with mechanical heart valve prosthesis: thromboprophylaxix with low molecular weight heparin. Thromb Res 124:262-7.
Aliyary S, Mariani MA, Verhorst PM, Hartmann M, Stoel MG, von Birgelen C. 2007. Staged therapeutic approach in spontaneous coronary dissection. Ann Thorac Surg 83:1879-81.
Almeda F, Barkatullah S, Kavinsky CJ. 2004. Spontaneous coronary artery dissection. Clin Cardiol 27:377-80.
American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons. Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD. 2006. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 114:84-231.
Ardehali R, Brinton TJ, Wilson AM, Gradman M, Vagelos RH, Lee DP. 2007. Recurrent spontaneous coronary artery dissection with transient left ventricular systolic dysfunction. Int J Cardiol 116:e48-50.
Arnold JR, West NE, van Gaal WJ, Karamitsos TD, Banning AP. 2008. The role of intravascular ultrasound in the management of spontaneous coronary artery dissection. Cardiovasc Ultrasound 6:24.
Bac DJ, Lotgering FK, Verkaaik AP, Deckers JW. 1995. Spontaneous coronary artery dissection during pregnancy and postpartum. Eur Heart J 16:136-8.
Badmanaban B, McCarty D, Mole DJ, McKeown PP, Sarsam MA. 2002. Spontaneous coronary artery dissection presenting as cardiac tamponade. Ann Thorac Surg 73:1324-6.
Bates SM, Greer IA, Pabinger I, Sofaer S, Hirsh J. 2008. Venous thromboembolism. Thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence Based Clinical Practice Guidelines, 8th edition. Chest 133:844-86.
Butchart EG, Gohlke-Barwolf C, Antunes MJ, et al. 2005. Recommendations for the management of patients after heart valve surgery. Eur Heart J 26:2463-71.
Chambers CE, Clark SL. 1994. Cardiac surgery during pregnancy. Clin Obstet Gynaecol 37:316-23.
Chan WS, Anand S, Ginsberg JS. 2000. Anticoagulation of pregnant women with mechanical heart valves: as systematic review of the literature. Arch Intern Med 160:191-6.
Chandrasekhar S, Cook CR, Collard CD. 2009. Cardiac surgery in the puerperium. Anesth Analg 108:777-85.
Cini R, Iezzi F, Sordini P, Pasceri V. 2008. Sponataneous left coronary artery dissection. Interact Cardiovasc Thorac Surg 7:943-4.
Clouse WD, Hallett JW, Jr, Schaff HV, et al. 2004. Acute aortic dissection: Population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc 79:176-80.
Dogan OF, Cakir H, Ozkara C, Erciyes A. 2012. Successful mitral valve replacement in a young pregnant patient. World J Cardiovasc Dis 2:151-4.
Erbel R, Alfonso F, Boileau C, et al. 2001. Diagnosis and management of aortic dissection. Eur Heart J 22:1642-81.
ESC Guidelines on the management of cardiovascular diseases during pregnancy. 2011. The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC) Endorsed by the European Society of Gynecology (ESG), the Association for European Paediatric Cardiology (AEPC), and the German Society for Gender Medicine (DGesGM). Euro Heart J 32:3147-97.
Heefner WA. 1973. Dissection hematoma of the coronary artery: a possible complication of oral contraceptive therapy. JAMA 223:550-1.
Inanç MT, Doğdu O, Kaya MG, Doğan A. 2009. Prosthetic mechanic valve thrombosis in pregnant women: a report of two cases. Turk Kardiyol Dern Ars 37:57-60.
Kearney P, Singh H, Hutter J, Khan S, Lee G, Lucey J. 1993. Spontaneous coronary artery dissection: A report of three cases and review of the literature. Postgrad Med J 69:940-5.
Kim KH, Jeong DS, Ahn H. 2007. Anticoagulation in pregnant women with a bileaflet mechanical cardiac valve replacement. Heart Surg Forum 10:267-70.
Koul AK, Hollander G, Moskovits N, Frankel R, Herrera L, Shani J. 2001. Coronary artery dissection during pregnancy and the postpartum period: Two case reports and review of literature. Catheter Cardiovasc Interv 52:88-94.
Krishnamurthy M, Desai R, Patel H. 2004. Spontaneous coronary artery dissection in the postpartum period: association with antiphospholipid antibody. Heart 90:53.
Larson EW, Edwards WD. 1984. Risk factors for aortic dissection: A necropsy study of 161 cases. Am J Cardiol 53:849-55.
Mehta R, O’Gara P, Bossone E, et al. 2002. Acute type A aortic dissection in the elderly: Clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 40:685-92.
Mészáros I, Mórocz J, Szlávi J, et al. 2000. Epidemiology and clinicopathology of aortic dissection. Chest 117:1271-8.
Nasiell J, Norman M, Lindqvist PG, Malmstedt J, Bottinga R, Blennow M. 2009. Aortic dissection in pregnancy: a life-threatening disease and a diagnosis of worth considering. Acta Obstet Gynecol Scand 88:1167-70.
Ozdemir B, Biçer M, Sentürk T, Beşli F, Yeşilbursa D. 2009. Mechanical valve thrombosis in a pregnant woman: a case report. Heart Surg Forum 12:305-7.
Parry AJ, Westaby S. 1996. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 61:1865-9.
Putnik SM, Nikolić BD, Divac IA, Ristić MN. 2011. Aortic dissection in the second trimester of pregnancy: is it possible to save both lives? Heart Surg Forum 14:307-8.
Regitz-Zagrosek V, Gohlke-Barwolf C, Geibel-Zehender A, Haas W, Kruck I, Nienaber C. 2008. Heart diseases in pregnancy. Clin Res Cardiol 97:630-65.
Rensing BJ, Kofflard M, Van den Brand MJ, Foley D. 1999. Spontaneous dissection of all three coronary arteries in a 33-week pregnant woman. Catheter Cardiovasc Interv 48:207-10.
Ricci G, Simeone R, Malisano M, Alberico S, Guaschino S. 1997. Coagulation and fibrinolysis changes in normal pregnancy. Increased levels of procoagulants and reduced levels of inhibitors during pregnancy induce a hypercoagulable state, combined with a reactive fibrinolysis. Eur J Obstet Gynecol Reprod Biol 73(1):31-6.
Salazar E, Zajarias A, Gutierrez N, Iturbe I. 1984. The problem of cardiac valve prostheses, anticoagulants, and pregnancy. Circulation 70:I169-77.
Shirakawa Y, Matsumiya G, Ohtake S, Sawa Y, Kagisaki K, Matsuda H. 2002. Emergency operation for sponataneous coronary artery dissection in young female. Asian Cardiovasc Thorac Ann 10:58-60.
Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology. 2003. Expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J 24:761-81.
Thistlethwaite PA, Trazi RY, Giordano FJ, Jamieson SW. 1998. Surgical management of spontaneous left main coronary artery dissection. Ann Thorac Surg 66:258-60.
Tsai TT, Evangelista A, Nienaber CA, et al. 2006. Long-term survival in patients presenting with type A acute aortic dissection: Insights from the International Registry of Acute Aortic Dissection (IRAD) Circulation 114(1 Suppl):I350-6.
von Kodolitsch Y, Schwartz AG, Nienaber CA. 2000. Clinical prediction of acute aortic dissection. Arch Intern Med 160:2977-82.
Weiss BM, von Segesser LK, Alon E, Seifert B, Turina MI. 1998. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984–1996. Am J Obstet Gynecol 179:1643-53.