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ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 93-96

Combined cesarean section and mitral valve replacement in severe symptomatic mitral valve disease with unfavorable valve anatomy: Experience at a tertiary referral center of North India


1 Department of Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Sangeeta Yadav
Type IV/72, Old Campus, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareilly Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_24_19

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  Abstract 


Objective: To discuss the management in a subset of patients with severe mitral valve disease having calcified, nonpliable valves not suitable for percutaneous balloon mitral valvuloplasty during pregnancy, presenting with Stage III–IV of the clinical classification of New York Heart Association.
Methods: Patients with nonpliable valves presenting with heart failure in pregnancy at advanced gestation were planned for simultaneous cesarean section followed by mitral valve replacement.
Results: All patients underwent successful surgery with good maternal and neonatal outcome.
Conclusion: Patients with severe mitral valvular disease in failure in pregnancy, who are at high risk of mortality in pregnancy or during and following delivery, benefit from combined surgery.

Keywords: Cesarean section, mitral stenosis, mitral valve replacement, pregnancy


How to cite this article:
Pradhan M, Yadav S, Singh N, Majumdar G, Agarwal SK. Combined cesarean section and mitral valve replacement in severe symptomatic mitral valve disease with unfavorable valve anatomy: Experience at a tertiary referral center of North India. Heart India 2019;7:93-6

How to cite this URL:
Pradhan M, Yadav S, Singh N, Majumdar G, Agarwal SK. Combined cesarean section and mitral valve replacement in severe symptomatic mitral valve disease with unfavorable valve anatomy: Experience at a tertiary referral center of North India. Heart India [serial online] 2019 [cited 2019 Oct 22];7:93-6. Available from: http://www.heartindia.net/text.asp?2019/7/3/93/268169




  Introduction Top


Cardiac disease is a major contributor to maternal mortality globally, particularly in low- and middle-income countries. Congenital heart disease accounts for most antenatal heart disease in high-income, industrialized countries.[1] This pattern differs in low- and middle-income countries, where 88%–90% of antenatal heart disease is attributable to rheumatic heart disease (RHD). RHD is the most common cardiac disease during pregnancy in India with mitral valve being most commonly affected.[2] It is an important cause of maternal mortality in India.[3]

It is advisable to avoid pregnancy in severe symptomatic mitral stenosis (MS) till the women undergo appropriate therapeutic intervention, but poor patient compliance and lack of understanding can result in unplanned pregnancy, especially in the developing country like India. Because of the hemodynamic changes of pregnancy, there is an increased cardiac workload which can result in unmasking of the undiagnosed condition or deterioration in the functional capacity and decompensation.[4] Most of the pregnant women with mild-to-moderate MS can tolerate the burden on the cardiovascular system caused by pregnancy. However, in cases with moderate-to-severe lesions, complications can occur.

The most common maternal complications in MS are pulmonary edema, atrial tachyarrhythmia, and thromboembolism, and the fetal complications are preterm delivery, fetal growth restriction, and stillbirth which occur with increasing frequency with increasing severity of stenosis and can be fatal.[5],[6] Even if the woman survives her antenatal period, there are chances of sudden deterioration during labor and immediate postpartum due to the hemodynamic shifts.[4] There is a need for multidisciplinary management in these patients. Medical therapy is the mainstay of treatment, and if still symptomatic in spite of the best efforts, percutaneous balloon mitral valvuloplasty (PBMV) and sometimes open-heart surgery becomes necessary to save the life of mother. At advanced gestation after fetal viability, consideration has to be given to both the life of mother and baby. Here, we present our data of four pregnant women who presented in the third trimester in Stage III–IV of the clinical classification of New York Heart Association (NYHA) and were found to be unfit for PBMV after echocardiographic assessment due to unfavorable valve anatomy. This article aims to address and highlight the management strategy in such high-risk cardiac condition encountered in women, who present late in pregnancy in heart failure not responding to medical therapy and are at very high risk of mortality.


  Methods Top


Four women having RHD with severe mitral valve disease presented in third trimester in NYHA III–IV in spite of medical therapy. All of them were found to have unfavourable echocardiographic parameters for percutaneous intervention. Because these patients were at high risk of mortality during labor and in the postpartum period, decision for combined surgery (simultaneous cesarean section [CS] followed by mitral valve replacement [MVR]) was taken after detailed discussion with cardiac surgeon and informed consent in all patients. Neonatology team was informed and was ready with all resuscitation measures. Femoral access for cardiopulmonary bypass (CPB) was established before the start of general anesthesia (GA) in readiness to establish CPB immediately if need arises, because of the possibility of cardiovascular collapse on induction of GA due to fixed output state. CS was performed after giving GA. After delivery of the baby, oxytocin infusion was started and per rectal tablet misoprostol was given to achieve and maintain good uterine tone and minimize bleeding. Uterine incision was closed after meticulous hemostasis and abdominal wound was packed. Thereafter, median sternotomy was performed and the patient was fully heparinized for CPB achieving the activated clotting time of more than 450. Aortic cannulation followed by bicaval venous cannulation was done and CPB initiated. Mitral valve was replaced with St Jude mechanical valve successfully in all cases. All patients were weaned off CPB uneventfully and protamine was administered. After completion of cardiac procedure and chest closure, uterine incision was inspected again and then abdomen was closed after ensuring proper hemostasis. Blood loss was average (500–800 ml) in all cases. After the procedure, all patients were taken to the intensive care unit for monitoring on inotropic support, which was tapered off gradually and all patients were extubated within 8–16 h. Uterotonic infusion was continued for 12 h after surgery, and oral anticoagulant was started on the first postoperative day.


  Results Top


Between January 2015 and December 2018, 105 patients of RHD presented in the Department of Maternal and Reproductive Health at Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. 57/105 (54.3%) women with RHD had prosthetic valve replacement done before pregnancy. 9/105 (8.6%) women were stable on medical management and did not require any intervention during pregnancy. 32/105 (30.5%) women had worsening symptoms with advancing pregnancy and underwent balloon mitral valvuloplasty in the department of cardiology. 28 of 32 women had PBMV in second trimester, and 4 women in third trimester after 28 weeks as they presented late in pregnancy. 3/105 (2.8%) women who had nonpliable valves not fit for PBMV had prosthetic valve replacement in the second trimester of pregnancy. 4/105 (3.8%) women presented in advanced gestation in NYHA III–IV on medical therapy were found to have unfavorable echocardiographic parameters for percutaneous intervention. 1 of 4 women had previous valvuloplasty and had developed restenosis. All the patients were admitted and were tried to stabilize medically by escalating the dose of drugs with some improvement. Because there was no significant improvement in spite of the best efforts to manage medically and there was a significant risk to the patient during labor and delivery, we planned for this strategy of simultaneous CS with MVR to prevent hemodynamic compromises during delivery and immediate postnatal period in these high-risk patients. The clinical parameters and outcome are presented in [Table 1].
Table 1: Clinical parameters and outcome in patients undergoing combined cesarean section followed by mitral valve replacement

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In all patients, there was a significant symptomatic improvement after the surgery, and there was no maternal or fetal death. The postoperative recovery was good, and all patients were discharged in stable condition in NYHA I or II on oral anticoagulant, aspirin, and diuretic. After discharge, all patients were followed up at 6 weeks, 6 months, 1 year, and yearly after that. Echocardiogram of all patients was done at follow-up. All the babies did well after delivery, except one who was born at 30 weeks (due to deranged Doppler) and required prolonged neonatal intensive care support, but had a good recovery. All the patients are in NYHA I at a mean follow-up of 18 months.


  Discussion Top


In developing country like India, many patients with severe MS present for the first time during pregnancy. Medical therapy is the preferred treatment during pregnancy; however, intervention is to be considered if they are severely symptomatic. Medical therapy for symptomatic MS during pregnancy largely involves careful diuresis, rate control for atrial tachyarrhythmia, and anticoagulation. In our cohort of patients, only 8.6% of women were stable on medical therapy. The rest of the patients had either prosthetic valve or required intervention in the form of PBMV or open-heart surgery for valve replacement. This is because our hospital is the tertiary referral center, and those patients who are high risk and could not be managed medically are being referred.

Due to the high risk of maternal and fetal morbidity and mortality in women who are highly symptomatic on medical therapy, the condition should be optimized by appropriate intervention. PBMV is the minimally invasive interventional procedure and is the favored intervention for pregnant women with severe MS and favorable anatomy. This can be performed under local anesthesia with significantly fewer fetal complications and a reduction in fetal and neonatal mortality.[7] It involves low risk and a very good success rate as demonstrated by the final mitral valve area achieved. This is followed by a marked decrease in the mitral valve gradient, left atrial pressure, and mean pulmonary artery pressure which results in symptomatic improvement. In our cohort of patients, PBMV was the intervention of choice in those women who were not responding to medical therapy.

Surgical valve replacement is reserved for the most severe cases which are unsuitable for PBMV. There was a group of patients unsuitable for PBMV due to unfavorable valve anatomy and were in NYHA III–IV. MVR was planned in these patients in second trimester. However, there was a subset of patients who presented late in advanced gestation. Decision at this stage becomes difficult because consideration has to be given to two lives. Labor and delivery are particularly stressful for women with severe MS. Pain, work of labor, and anxiety cause tachycardia and increase chances of rate-related heart failure. Cardiac output increases 50% during contractions. Clinical status often deteriorates even more during the immediate postpartum period when venous return increases after the fetus is removed and caval compression has been relieved. Because these patients were at high risk of mortality during labor and in the postpartum period, decision for combined surgery (simultaneous CS and MVR) was taken.

All our patients had severe MS except one who had severe mitral regurgitation with moderate MS. The coexistence of MS and regurgitation can often have pathophysiological consequences that are incremental to the degree of either alone. Our patient also presented in NYHA IV. Patients with mixed moderate-to-severe regurgitation and stenosis had pregnancy outcomes similar to those with severe MS.[8] The options for the treatment of pure mitral regurgitation and mixed valvular disease, which are more common in younger women of childbearing age, are almost exclusively surgical.

CPB during pregnancy poses maternal and fetal risk, and although maternal mortality rate has been found to be the same as in nonpregnant woman in the current era, fetal mortality is still high.[9],[10] Hence, decision was taken to do cesarean first followed by MVR.

CPB in the immediate postpartum period might result in severe uterine bleeding due to high-dose heparinization and use of anesthetic drugs which cause uterine relaxation. Keeping this in mind, we undertook all the precautions and none of the cases had significant bleeding. Continuous infusion of oxytocin and per rectal misoprostol helped in maintaining uterine tone and minimized bleeding during the cardiac procedure. Further care was taken to achieve meticulous hemostasis before closing the abdomen by reinspection of uterine incision and tone.

Preterm birth and low-birth-weight babies are known as the major neonatal complications in women with heart disease in pregnancy. Perinatal outcome is more dependent on severity of symptoms during pregnancy rather than the duration and type of heart disease.[11] In our patients, 3 out of 4 babies were small for gestational age and one was delivered preterm due to abnormal Doppler.

Few case reports of combined CS and MVR have been described in literature. Devbhandari et al. have described redo MVR with CS following malfunction of mechanical mitral valve.[12] Duvan et al. and Tempe et al. have reported redo MVR after CS in mechanical mitral valve thrombosis.[13],[14] Atanasova reported a case of CS with MVR for infective endocarditis with vegetation presenting with heart failure.[15] We could find only one case of combined CS with MVR for severe symptomatic MS.[16]

Based on our experience of small number of patients, we opine that the type and time of intervention needs to be selected using multiple clinical and echocardiographic variables. Our patients had significant improvement in their clinical status and had good perinatal outcome.


  Conclusion Top


Pregnancy in women with severe symptomatic MS is associated with significant risk for adverse maternal and neonatal outcome and may even lead to death. Medical therapy is the first choice but cardiac surgery may become necessary sometimes for inevitable indications. All our cases had successful valve replacement immediately after CS. This strategy of simultaneous cesarean and open-heart surgery seems reasonable and can be successfully employed and life-saving for severely symptomatic women who are unfit for percutaneous intervention and are unable to bear the stress of labor and delivery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001;104:515-21.  Back to cited text no. 1
    
2.
Bhatla N, Lal S, Behera G, Kriplani A, Mittal S, Agarwal N, et al. Cardiac disease in pregnancy. Int J Gynaecol Obstet 2003;82:153-9.  Back to cited text no. 2
    
3.
Konar H. Medical disorders in pregnancy – Who should see the women? J Indian Med Assoc 2004;102:131.  Back to cited text no. 3
    
4.
Abbas AE, Lester SJ, Connolly H. Pregnancy and the cardiovascular system. Int J Cardiol 2005;98:179-89.  Back to cited text no. 4
    
5.
Silversides CK, Colman JM, Sermer M, Siu SC. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003;91:1382-5.  Back to cited text no. 5
    
6.
Hameed A, Karaalp IS, Tummala PP, Wani OR, Canetti M, Akhter MW, et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol 2001;37:893-9.  Back to cited text no. 6
    
7.
de Souza JA, Martinez EE Jr., Ambrose JA, Alves CM, Born D, Buffolo E, et al. Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy. J Am Coll Cardiol 2001;37:900-3.  Back to cited text no. 7
    
8.
van Hagen IM, Thorne SA, Taha N, Youssef G, Elnagar A, Gabriel H, et al. Pregnancy outcomes in women with rheumatic mitral valve disease: Results from the registry of pregnancy and cardiac disease. Circulation 2018;137:806-16.  Back to cited text no. 8
    
9.
Arnoni RT, Arnoni AS, Bonini RC, de Almeida AF, Neto CA, Dinkhuysen JJ, et al. Risk factors associated with cardiac surgery during pregnancy. Ann Thorac Surg 2003;76:1605-8.  Back to cited text no. 9
    
10.
John AS, Gurley F, Schaff HV, Warnes CA, Phillips SD, Arendt KW, et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 2011;91:1191-6.  Back to cited text no. 10
    
11.
de Swiet M, editor. Heart disease in pregnancy. In: Medical Disorders in Obstetric Practice. Oxford: Blackwell; 1984. p. 483-504.  Back to cited text no. 11
    
12.
Devbhandari MP, Jeeji R, Bewsher M, Odom N. Emergency redo mitral valve replacement and caesarean section in a patient with previous atrioventricular septal defect repair in childhood. Interact Cardiovasc Thorac Surg 2009;8:164-5.  Back to cited text no. 12
    
13.
Duvan İ, Sungur ÜP, Onuk BE, Ateş MŞ, Karacan İS, Kurtoǧlu M, et al. Emergency redo mitral valve replacement immediately after caesarean section. J Tehran Heart Cent 2016;11:85-7.  Back to cited text no. 13
    
14.
Tempe DK, Virmani S, Tempe A, Sharma JB, Datt V, Nigam M. Anaesthetic management of emergency caesarean section and reoperative mitral valve replacement in a 32 weeks parturient: A case report. Ann Card Anaesth 2002;5:63-7.  Back to cited text no. 14
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15.
Atanasova G. Combined caesarian section, mitral valve replacement and tricuspid valve repair for infective endocarditis: Case report and management considerations. Pediatr Dimens 2016;1:98-101.  Back to cited text no. 15
    
16.
Birincioglu CL, Küçüker SA, Yapar EG, Yildiz U, Ulus AT, Yamak B, et al. Perinatal mitral valve interventions: A report of 10 cases. Ann Thorac Surg 1999;67:1312-4.  Back to cited text no. 16
    



 
 
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