Poor Outcome of Surgical Management of Acute Malfunctioning Mechanical Mitral Valve During Pregnancy. Should Centers with Limited Resources Find Different Options?
Keywords:Mitral valve replacement; pregnancy; stuck valve; emergency; mechanical valves
Background: Rheumatic heart disease (RHD) is the most common cardiac disease in pregnancy in developing countries with the mitral valve being the most affected. In this study, the results of surgical intervention in pregnant women presented with acute malfunctioning mechanical mitral valve were discussed.
Methods: All patients underwent emergency redo mitral valve replacement due to acute malfunctioning mechanical mitral valve during pregnancy in a single center between January 2005 and December 2017. These patients were retrospectively analyzed. Additionally, anticoagulation strategy before the event and outcomes for the mother and the fetus were outlined.
Results: Between 2005 and 2017, 16 pregnant women arrived in a single tertiary center with acute malfunctioning mechanical mitral valves. The mean gestational age at the time of presentation was 13.19 ± 2.6 weeks. Fifteen out of the 16 patients changed their anticoagulation regimen either with or without medical advice. After replacing the valve, cardiopulmonary bypass successfully was weaned in 12 patients, who were transferred to the ICU sedated and ventilated with variable doses of chemical Inotropes. The remaining 4 patients died on the table after failure of weaning from bypass. In one case, the patient developed immediate postoperative stroke with the Glasgow Coma Scale (GCS) of 7, CT brain revealed massive infarction, her fetus was not viable, she remained sedated and ventilated, and she passed away on post-operative Day 12, due to pneumonia and sepsis. Another patient, with a viable fetus, passed away on post-operative Day 1, due to low cardiac output.
Conclusion: Acute malfunctioning MHV during pregnancy represents a real dilemma to patients and caregivers. It carries high fetal and maternal morbidity and mortality, especially in centers with limited resources. We believe that an alternative plane must be formulated for such patients to avoid devastating complications, including maternal and fetal deaths.
Abdel-Moula, A., et al. 1998. Prevalence of rheumatic heart disease among school children in Alexandria, Egypt: A prospective epidemiological study. The Journal of the Egyptian Public Health Association 73(3-4): p. 233-254.
Arnoni, R.T., et al. 2003. Risk factors associated with cardiac surgery during pregnancy. 76(5): p. 1605-1608.
Becker, R.M. 1983. Intracardiac surgery in pregnant women. The Annals of Thoracic Surgery 36(4): p. 453-458.
Bhatla, N., et al. 2003. Cardiac disease in pregnancy. International Journal of Gynecology & Obstetrics 82(2): p. 153-159.
Chan, W.S., S. Anand, and J.S.J.A.o.i.m. Ginsberg, 2000. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. 160(2): p. 191-196.
Davies, G.A. and W.N. Herbert. 2007. HEART DISEASE IN PREGNANCY 2: Congenital Heart Disease in Pregnancy. Journal of Obstetrics and Gynaecology Canada 29(5): p. 409-414.
Elamrousy, D.M., H. Al-Asy, and W. Mawlana, 2014. Acute Rheumatic Fever in Egyptian Children: A 30-Year Experience in a Tertiary Hospital. Journal of Pediatric Sciences 6.
Elassy, S.M., A.A. Elmidany, and H.Y. Elbawab. 2014. Urgent cardiac surgery during pregnancy: a continuous challenge. The Annals of Thoracic Surgery 97(5): p. 1624-1629.
Elkayam, U. 1996. Anticoagulation in pregnant women with prosthetic heart valves: a double jeopardy. Journal of the American College of Cardiology.
Endorsed by the European Society of Gynecology , t.A.f.E.P.C., et al. 2011. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC) 32(24): p. 3147-3197.
Lengyel, M. and L. Vandor. 2001. The role of thrombolysis in the management of left-sided prosthetic valve thrombosis: a study of 85 cases diagnosed by transesophageal echocardiography. The Journal of Heart Valve Disease 10(5): p. 636-649.
Keogh, B. and R. Kinsman. 1999. National adult cardiac surgical database report. London: Society of Cardiothoracic Surgeons of Great Britain and Ireland.
Korkmaz, A.A., et al. 2008. Stuck mechanical valve in pregnancy. Journal of cardiac surgery, 23(6): p. 790-792.
Members, A.T.F., et al. 2012. Guidelines on the management of valvular heart disease (version 2012) The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Journal of Cardio-Thoracic Surgery 42(4): p. S1-S44.
Members:, A.T.F., et al. 2017. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. European Journal of Cardio-Thoracic Surgery 52(4): p. 616-664.
Nishimura, R.A., et al. 2017. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology 70(2): p. 252-289.
Oles, D., et al. 2001. Emergency redo mitral valve replacement in a 27-year-old pregnant female with a clotted prosthetic mitral valve, preoperative fetal demise and postoperative ventricular assist device: a case report. Perfusion 16(2): p. 159-164.
Ozkan, M., et al. 2013. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation 128(5): p. 532-40.
Parry, A.J. and S. Westaby. 1996. Cardiopulmonary bypass during pregnancy. The Annals of Thoracic Surgery 61(6): p. 1865-1869.
Regitz-Zagrosek, V., et al. 2011. European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM). ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC) 32(24): p. 3147-97.
Sousa Gomes, M., M. Guimarães, and N. Montenegro. 2018. Thrombolysis in pregnancy: a literature review. The Journal of Maternal-Fetal & Neonatal Medicine p. 1-11.
van Hagen, I.M., et al. 2015. Pregnancy in women with a mechanical heart valve: data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). Circulation, p. CIRCULATIONAHA. 115.015242.
Vause, S., et al. 2017. Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG: An International Journal of Obstetrics & Gynaecology 124(9): p. 1411-1419.
Vitale, N., et al. 1999. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. 33(6): p. 1637-1641.
Weiss, B.M., et al. 1998. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996. American journal of obstetrics and gynecology 179(6): p. 1643-1653.
Xu, Z., et al. 2016. Anticoagulation regimens during pregnancy in patients with mechanical heart valves: a systematic review and meta-analysis. 32(10): p. 1248. e1-1248. e9.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).