Cases in Structural Heart Disease Suzanne J Baron MD MSc Director of Interventional Cardiology Research Lahey Hospital and Medical Center Burlington MA Disclosures Consulting Fees Abbott Inc ID: 935980
Download Presentation The PPT/PDF document "SCAI Women in Innovations Symposium" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
SCAI Women in Innovations SymposiumCases in Structural Heart Disease
Suzanne J. Baron MD MSc
Director of Interventional Cardiology Research
Lahey
Hospital and Medical Center, Burlington MA
Slide2Disclosures
Consulting Fees
- Abbott Inc.
Advisory Board Fees
Boston Scientific Corporation Inc.
Abiomed
Research Support
- Boston Scientific Corporation Inc.
Slide3History
Chief Complaint
: 32 y/o G1P0 female at 9 weeks gestation presents to outside Emergency Department with nausea/vomiting.
HPI:
Patient reports increasing nausea/vomiting over the 3 days prior to presentation with resulting decreased PO intake. She denies fevers, chills, rashes, sick contacts, diarrhea, dysuria, cough, or dyspnea.
PMHx
: none
Slide4History
Home Medications
: Prenatal vitamin
Allergies:
None
:
FHx
:
No family
hx
of heart disease
SHx
: Ethiopian Immigrant; Married; No tobacco or alcohol use
Slide5Hospital Course
Anti-emetic and 500cc IVF bolus administered for management of mild dehydration and nausea secondary to hyperemesis
gravidarum
Patient subsequently developed acute onset of dyspnea with mild hypoxia (O2 sat 92%) concerning for flash pulmonary edema
20mg IV Lasix was administered with improvement in her respiratory status and TTE was obtained
Slide6Echocardiogram
Slide7Echocardiogram
Slide8Echocardiogram
Slide9Echocardiogram
Slide10Echocardiogram
Slide11Echocardiogram
Slide12Echocardiogram
Slide13Echocardiogram
Preserved LVEF 60%
Severe rheumatic mitral stenosis with mean gradient 22mmHg
Trace mitral regurgitation
Moderate to severe aortic stenosis with mean gradient of 32mmHg
Moderate aortic regurgitation
Slide14Management
Patient was transferred to tertiary care center for further evaluation of her valvular heart disease
Structural cardiology and maternal fetal medicine were consulted
Options discussed included . . .
Medical management
Percutaneous mitral
valvuloplasty
Timing?
Termination of pregnancy followed by surgical MVR/AVR
Slide15Management
Patient was transferred to tertiary care center for further evaluation of her valvular heart disease
Structural cardiology and maternal fetal medicine were consulted
Options discussed included . . .
Medical management
Percutaneous mitral
valvuloplasty
Timing – 2
nd
trimester
Termination of pregnancy followed by surgical MVR/AVR
Slide16Percutaneous Mitral
Valvuloplasty
Procedural considerations
Sedation
Fluoroscopy exposure
Echo guidance
Risk of resulting mitral regurgitation
Slide17Percutaneous Mitral
Valvuloplasty
Procedural considerations
Sedation
Cardiac anesthesia to administer
Fluoroscopy exposure
Abdomen draped in lead
Access obtained with ultrasound
Frame rate decreased to 3/sec; no cine
Echo Guidance
TEE and TTE
Risk of resulting mitral regurgitation
Inoue technique with plan for single inflation
Slide18Pre-Percutaneous Mitral
Valvuloplasty
- TEE
Slide19Percutaneous Mitral
Valvuloplasty
Access obtained in RFA and RFV
RHC – RA 8, RV 45/11, PA 45/25 (35), PCWP 30 and CO 6.9 L/min
Transseptal
performed under TEE guidance
Simultaneous LA and LV pressures obtained and demonstrated mean LA 35, mean MV gradient of 24mmHg with MVA 1.24cm
2
Slide20Percutaneous Mitral
Valvuloplasty
Single inflation performed with 26mm Inoue balloon
Repeat hemodynamics demonstrated PCWP 18, mean LA 20, mean MV gradient of 10mmHg and MVA 2.2cm
2
Given significant decrease in MV gradient as well as LA and PCWP pressures, decision made to conclude procedure at this time
Total Radiation dose – 106mGy
Slide21Post-Percutaneous Mitral
Valvuloplasty
- TTE
Slide22Post-Procedural Course
Post PMV Procedure
Patient seen by MFM in PACU and fetus determined to be in no distress
POD#1 TTE revealed findings c/w intra-procedural TTE post
valvuloplasty
Patient discharged home on POD#1 on Toprol 25mg QD and Lasix 20mg daily
2
nd
and 3
rd
trimester of Pregnancy
Patient followed in Heart Disease in Pregnancy Clinic
Repeat TTE in 3
rd
trimester revealed stable MV gradient of 11mmHg with mild MR, moderate AR and moderate/severe AS
Patient proceeded with planned vaginal delivery of healthy baby girl (7lbs 8oz) at 39 weeks
After pregnancy, patient referred to CT surgery for AVR/MVR
Slide23Management of Mitral Stenosis in Pregnancy
Rheumatic mitral stenosis is the most common valve lesion in women of childbearing age
Most common complications during pregnancy are atrial arrhythmias, pulmonary edema and decrease in functional capacity
Pulmonary edema ~56-78% and Atrial arrhythmias ~33% in pts with severe MS
1,2
Complications most common in 3
rd
trimester when hemodynamic changes of pregnancy (e.g. increases in HR, CO, red blood cell mass and plasma volume) most pronounced
Silversides et al. Am J
Cardiol
2003; 91: 1382-5.
Hameed et al. JACC 2001; 37: 893-99.
Slide24Management of Mitral Stenosis in Pregnancy
Fetal complications are increased with high rates of pre-term delivery, IUGR and fetal death
Treatment includes
Diuretic and BB therapy for pulmonary edema
Restoration of sinus rhythm and a/c for women with atrial fibrillation
PMV if medical therapy fails
Surgical valve replacement if all other therapies fail (significant risk of fetal mortality)
Close monitoring by MFM and Cardiology throughout pregnancy
Elkayam
et al. JACC 2016; DOI: 10.1016/j.jack.2016.05.048.